Assessment and Management of Suicide Risk in Children and Adolescents

This article presents a pragmatic approach to assessing and managing suicide risk in children and adolescents. We first present general recommendations for conducting risk assessments with children and adolescents, followed by an algorithm for designating risk. Risk assessment and designation should be based on both distal (i.e., a prior history of self-harm behaviors) and proximal (i.e., suicide ideation, plans, intent, and preparations) predictors of suicide attempt. We then discuss safety planning as an easy-to-implement approach for intervening and managing suicide risk when working with children and adolescents. We end with a case example illustrating the implementation of risk assessment, risk designation, and safety planning with an adolescent client and her mother.     

A comprehensive and concise assessment of suicide risk

Because suicide is one of the few fatal consequences of psychiatric illness and is a source of extraordinary stress for loved ones and the clinician, accurate assessment of suicidal risk is an essential aspect of the mental health profession. Innumerable individual differences, along with the low base rate of suicide, make assessment a challenging task in clinical practice that is both delicate and time consuming. In this article, the authors recommend examining and incorporating each patient's personal characteristics, dispositional factors, situational factors, and current presentation of symptoms into a unique individual picture of suicidal risk. This portrait of potential for suicidal behavior can, in turn, be used to evaluate risk and design a course of action. This thorough yet concise approach will likely reduce omissions in assessment, and hopefully lead to fewer false negatives and fewer deaths of suicidal patients.     

Documenting suicide risk assessments and proportionate clinical actions to improve patient safety and mitigate legal risk

Few clinical practices are as important for simultaneously augmenting patient safety and mitigating legal risk as the judicious evaluation and stratification of a patient's risk for suicide, proportionate clinical actions based thereon taken by the healthcare provider, and contemporaneous documentation of the foregoing. In this article, we draw from our combined decades of multidisciplinary experience as a clinical psychologist, forensic psychiatrist, medical malpractice attorney, and clinical psychology trainee to discuss the documentation of suicide risk assessment and management as a conduit to patient safety and legal risk mitigation. We additionally highlight documentation as a core clinical competency across disciplines and note areas of improvement, such as increased training, to bolster documentation practices.     

Suicide Risk Factors In Alcohol Abuse

ABSTRACT: The “clinical model” approach to estimating suicide risk assumes that persons sharing specific attributes will also share certain indicators of vulnerability to suicide. This would warrant an empirically derived risk assessment scale applicable only to persons with those attributes. Nine hundred seventy eight persons at risk for suicide who met our criteria for alcohol abuse were interviewed at length and followed for two years, during which 53 (5.5 percent) committed suicide. Eleven variables which best differentiated those who suicided from those who did not in an index set were then applied to an independent validation set. Clinical implications of the findings are discussed.     

Reevaluating Suicidal Behaviors: Comparing Assessment Methods to Improve Risk Evaluations

This study examined suicide assessment validity by comparing methods of measuring current risk associated with past suicidal behaviors. Three independent samples (Ns = 359, 1007, and 713; aged 18–76 years) all included participants covering a broad spectrum of suicidality. Information theory, item response theory, general linear modeling, and linear regression modeling tested seven competing methods/models of assessing past suicidal behaviors in relation to current suicidality. In contrast to contemporary theories, ANOVA results showed suicide plans can indicate higher risk than suicide attempts when intent to die is higher. Contrary to popular practice, evidence demonstrated that defining risk by suicide ideation (yes/no), attempts or serious attempts (yes/no), are false dichotomies, were the least valid models tested, and failed to explain substantial explainable variance in suicidality/risk. A newly proposed model, differentiating behaviors with or without intent to die, was the most efficacious dichotomous method. However, as predicted, continuous variables were superior to dichotomous. The proposed suicidal barometer model (SBM) exhibited robust evidence as the best available model for evaluating suicidal behaviors in all samples (100 % probability), explaining 47–61 % of suicidality variance and provided incremental improvement in risk evaluations. Findings were consistent by sample, sex, age-group, ethnicity, and psychiatric history. This study, and related evidence, demonstrate that there is a clear and present need for updating measures, clinical training and core competencies, for valid assessment and risk formulation.     

Using the Linehan Risk Assessment and Management Protocol With a Chronically Suicidal Patient: A Case Report

The Linehan Risk Assessment and Management Protocol (LRAMP) is an empirically supported, comprehensive framework used to assess suicide risk and protective factors, and provide a guide for the therapist to consider reasonable options for intervening on suicidal behavior. This protocol includes a structured checklist for assessing, managing, and documenting suicide risk. It also structures the documentation to clearly describe the presentation, assessment, in-session interventions, decision-making process, and follow-up to other members of the treatment team. This paper describes a case in which the LRAMP was used to guide the assessment, intervention, and documentation of the suicidal behavior of a patient, “Ann,” being treated with outpatient Dialectical Behavioral Therapy in a community mental health clinic. Each section of the LRAMP is discussed as it was used with this complex patient, who had history of high utilization of acute psychiatric services. Application of the LRAMP included the assessment of risk and protective factors, and the use of an individualized crisis plan that engaged the patient, her family, the therapist, and the clinical team, to decrease acute risk, continue outpatient treatment, and avoid inpatient hospitalization. The considerations for documenting clinical decision-making with chronically suicidal patients are discussed.     

The assessment and management of suicide risk: state of workshop education

A systematic search of popular and scholarly databases identified workshops that addressed general clinical competence in the assessment or management of suicide risk, targeted mental health professionals, and had at least one peer-reviewed publication. We surveyed workshop developers and examined empirical articles associated with each workshop. The state of workshop education is characterized by presenting the learning objectives, educational formats, instructor factors, and evaluation studies. Workshops are efficacious for transferring knowledge and shifting attitudes; however, their role in improving clinical care and outcomes of suicidal patients has yet to be determined.     

The role of objective personality inventories in suicide risk assessment: an evaluation and proposal.

Objective personality assessment instruments offer a comparatively underutilized source of clinical data in attempts to evaluate and predict risk for suicide. In contrast to focal suicide risk measures, global personality inventories may be useful in identification of long-standing styles that predispose persons to eventual suicidal behavior. This article reviews the empirical literature regarding the efficacy of established personality inventories in predicting suicidality. The authors offer several recommendations for future research with these measures and conclude that such objective personality instruments offer only marginal utility as sources of clinical information in comprehensive suicide risk evaluations. Personality inventories may offer greatest utility in long-term assessment of suicide risk.     

The Practice of Suicide Assessment and Management by Marriage and Family Therapists

Abstract

Over 90% of mental health providers encounter suicidal clients. However, the majority of marriage and family therapists (MFTs) are not exposed to suicide-specific trainings within their clinical coursework. Due to the lack of consistent training protocols for suicide assessment and management among MFTs, this qualitative study identified common MFT responses to suicidal clients, including assessment of risk severity and intervention modalities. Responses were then compared to best practices for suicidal clients. Participants inconsistently adhered to best practices identified in the larger field of mental health, revealing the need for increased MFT training on suicide to ensure appropriate and effective care.     

In a search for meaning: challenging the accepted know-how of working with suicide risk

This opinion piece considers the current predominance of assessment tools and strategies in working with people at risk of suicide, and questions their efficacy and how they are privileged in day to day mental health practice. While such tools and an evidence-based ‘scientific’ approach to assessment clearly has its place, the author instead asserts that the modus operandi of therapy – a discursive based exploration – has much more to offer and should be the primary intervention in understanding suicide potential. Helping the client to gain insight into the meaning of their suicidality helps position the client – and practitioner – in the best possible place to reduce risk.     

Considerations Regarding Online Methods for Suicide‐Related Research and Suicide Risk Assessment

Frequent advances in technology provide new and exciting opportunities for conducting suicide research and suicide risk assessments. However, to the authors' knowledge, best practices for using technology, specifically the Internet, to conduct research protocols involving suicide risk assessments have not been examined. In research contexts, the use of technology for research on suicidal behavior and suicide risk assessment can offer benefits relative to other forms of data collection. These advantages, which include increased validity, feasibility, and efficiency, as well as improvements in data collection and management, are presented. Considerations regarding the implementation of an online system for suicide risk assessment as well as limitations and future directions are discussed.     

Suicide Risk Assessment and Risk Formulation Part II: Suicide Risk Formulation and the Determination of Levels of Risk

The suicide risk formulation (SRF) is dependent on the data gathered in the suicide risk assessment. The SRF assigns a level of suicide risk that is intended to inform decisions about triage, treatment, management, and preventive interventions. However, there is little published about how to stratify and formulate suicide risk, what are the criteria for assigning levels of risk, and how triage and treatment decisions are correlated with levels of risk. The salient clinical issues that define an SRF are reviewed and modeling is suggested for an SRF that might guide clinical researchers toward the refinement of an SRF process.     

Suicide risk assessment: Clinicians’ confidence in their professional judgment

Suicide risk assessment is a critical component of mental health practice for which the stakes are high and the outcomes uncertain. This research examines the consistency with which clinicians make determinations of suicide risk and factors influencing clinical confidence. Seventy-one social workers interviewed two standardized patients performing in scenarios depicting suicidal ideation, judged whether the patient required hospitalization, and completed standardized suicide risk assessment measures. Self-ratings and qualitative interviews explored participants’ confidence in their judgment of risk. Participants had highly divergent views regarding whether or not the risk of suicide was sufficiently high to require hospitalization. However, regardless of the ultimate decision reached, participants were equally confident when recommending either clinical course of action. The variation in risk assessment appraisals in this study, despite at times high rates of confidence in risk appraisals, speaks to the need for ongoing training, consultation, and increased decision support strategies.     

The cultural theory and model of suicide

A growing body of research has demonstrated important variations in the prevalence, nature, and correlates of suicide across ethnic and sexual minority groups. Despite these developments, existing clinical and research approaches to suicide assessment and prevention have not incorporated cultural variations in any systematic way. In addition, theoretical models of suicide have been largely devoid of cultural influence. The current report presents a comprehensive analysis of literature describing the relationship between cultural factors and suicide in three major ethnic groups (African Americans, Asian Americans, and Latinos) and LGBTQ¹ sexual minority groups. We utilized an inductive approach to synthesize this variegated body of research into four factors that account for 95% of existing culturally specific risk data: cultural sanctions, idioms of distress, minority stress, and social discord. These four cultural factors are then integrated into a theoretical framework: the Cultural Model of Suicide. Three theoretical principles emerge: (1) culture affects the types of stressors that lead to suicide; (2) cultural meanings associated with stressors and suicide affect the development of suicidal tendencies, one's threshold of tolerance for psychological pain, and subsequent suicidal acts; and (3) culture affects how suicidal thoughts, intent, plans, and attempts are expressed. The Cultural Model of Suicide provides an empirically guided cohesive approach that can inform culturally competent suicide assessment and prevention efforts in future research and clinical practice. Including both ethnic and sexual minorities in our investigations ensures advancement along a multiple identities perspective.     

Understanding suicidal ideation and assessing for risk

The UK government's health strategy, The Health of the Nation , included a target for reducing the population suicide rates by 15% over an 8-year period [Department of Health (1992), London: HMSO]. This thrust has been carried forward in subsequent work embodied in the ninth standard of the National Service Framework for Mental Health [Department of Health (1999), London: HMSO] and Safety First: FiveYear Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness [Department of Health (2001), London: HMSO]. A crucial aspect in reducing suicide rates is the accurate assessment of those who may be at risk to enable appropriate interventions to take place.While any person who wants to end his or her own life may find a way to do so, it is most important for the clinician to approach any potential suicide with the conviction that it is possible to prevent at least some suicides. This paper outlines best practice regarding the exploration and assessment of suicidal ideation and suicidal potential.     

VA telemental health: suicide assessment

The Department of Veterans Affairs (VA) encompasses one of the largest telemental health networks in the world, with over 45,000 videoconferencing and over 5,000 home telemental health encounters annually. Recently, the VA designated suicide prevention as a major priority, with telehealth modalities providing opportunities for remote interventions. Suicide risk assessments, using videoconferencing, are now documented in the literature, as are current studies that find telemental health to be equivalent to face-to-face treatment. Remote assessment of suicidality, however, involves complex legal issues: licensing requirements for remote delivery of care, legal procedures for involuntary detainment and commitment of potentially harmful patients, and liability questions related to the remote nature of the mental health service. VA best practices for remote suicide risk assessment include paradigms for establishing procedures in the context of legal challenges (licensing and involuntary detainment/commitment), for utilizing clinical assessment and triage decision protocols, and for contingency planning to optimize patient care and reduce liability.     

A Standard of Care for the Assessment of Suicide Risk and Associated Treatment: The Florida State University Psychology Clinic as an Example

The Florida State University has established a set of guidelines to be used as a standard of care for suicide. This standard of care guides therapists through a suicide risk assessment that focuses on key variables related to suicidal behavior that are among the best predictors of completed suicide. This standard of care includes necessary components of suicide risk assessment, critical steps to follow to ensure the safety of suicidal patients, treatment recommendations, and guidelines for minimizing the legal risk of the therapist. Though this standard of care was developed in a research and training clinic, these principles may be applied to all clinicians offering psychological services to patients, regardless of the nature of the clinic or setting.     

Evaluation of the Recognizing and Responding to Suicide Risk Training

Changes in attitudes, confidence, and practice behaviors were assessed among 452 clinicians who completed the training, Recognizing and Responding to Suicide Risk, and who work with clients at risk for suicide. Data were collected at three time points. Scores on measures of attitudes toward suicide prevention and confidence to work with clients at risk for suicide improved over time. Clinical practice behaviors improved for assessing and formulating suicide risk, developing suicide prevention treatment plans, and responding to vignettes. Results suggest training can improve clinicians’ attitudes toward suicide, confidence to work with clients at risk for suicide, and, most importantly, clinical practice skills.     

Post-Admission Cognitive Therapy: A Brief Intervention for Psychiatric Inpatients Admitted After a Suicide Attempt

To date, no empirically based inpatient intervention for individuals who have attempted suicide exists. We present an overview of a novel psychotherapeutic approach, Post-Admission Cognitive Therapy (PACT), currently under development and empirical testing for inpatients who have been admitted for a recent suicide attempt. PACT is adapted from an efficacious and brief outpatient cognitive therapy protocol (Brown, Henriques, Ratto, & Beck, 2002; Brown et al., 2005) for inpatient delivery to individuals with recent suicide attempts. Within a cognitive framework, attempting suicide is conceptualized as a maladaptive coping strategy that deserves immediate targeted clinical attention regardless of the patient's diagnosis. The primary aims of PACT are to reduce the likelihood of suicide attempt recurrence as well as decrease the severity of established psychological risk factors for suicide. The three phases of PACT involve (1) building a therapeutic alliance and developing a cognitive conceptualization based on the recent suicide attempt; (2) instilling hope, practicing effective coping strategies, and addressing problem-solving deficits; and (3) preventing relapse, constructing a safety plan, and promoting timely linkage with outpatient aftercare services. The efficacy of PACT as a targeted inpatient treatment package remains to be established. The cognitive behavioral components of PACT, as described here, are based on evidence-informed practices aimed at improving the quality of care provided to inpatients following a suicide attempt.     

Risk for Suicidal Ideation and Attempt among a Primary Care Sample of Adolescents Engaging in Nonsuicidal Self‐Injury

One in five adolescents in the United States has engaged in nonsuicidal self‐injury (NSSI), one in eight have had serious thoughts of suicide, and one in 25 have attempted suicide. Research suggests that NSSI may increase risk for suicide attempt, yet little is known about the relationship between NSSI and suicidal ideation or attempts. In a primary care setting, 1,561 youth aged 14–24 years completed a brief, comprehensive, mental health screen as part of a routine well visit to determine which factors were most likely to predict suicidal ideation and attempt among youth engaging in NSSI. Results of recursive partitioning revealed that current depression and history of alcohol use best differentiated youth engaging in NSSI with low versus high risk for suicidal ideation and attempts. This simple algorithm is presented as a clinical screening tool that might aid medical providers in determining which youth would benefit from more intensive assessment and intervention.