CCPR: In the office setting, how should we assess suicidal risk?
Dr. Pfeffer: In the office setting, assessing suicide risk is no different than for emergency service or psychiatric inpatient settings. However, psychiatric assessment is needed, including specific questions about suicidal thinking, planning, and attempts, plus inquiry about other psychiatric, family, social, and neurobiological risk factors. It is important to recognize that younger children will minimize their understanding of risk for death. They might think one aspirin is lethal, and might not think jumping from a window will kill them. Additionally, frequency of suicidal thinking is an estimation of suicidal risk. Those with frequent suicidal ideation may be at higher risk for suicidal acts. Ask questions such as, “How many times in each hour do you think about suicide?” Ask about the amount of time spent, and how often this occurs during the day. Is it once or twice a day? New approaches to track suicidal thinking are in development, such as cell phone apps that catalog, chart, and analyze the timing, frequency, and intensity of suicidal thinking.
CCPR: That’s very helpful. Is there anything else we should know about the assessment?
Dr. Pfeffer: Clinicians need to be methodical, but not tedious in going through all the risk factors. Keep an order in mind while doing this, and use a style that is conversational; however, avoid a checklist approach, which can become stilted and let patients deny or minimize what they are thinking. More information is apparent during a discussion. Child psychiatrists need to be skilled, and this needs to be part of fellowship training with supervision. It is important for the therapist to talk very openly, and it’s best to use a stepwise approach in the type of words we use.
CCPR: This is really helpful. Can you tell us how you phrase these questions?
Dr. Pfeffer: For example, try to ask, “Do you ever think that you want to die? What did you think about?” If a child starts with the word suicide, try to understand what the child means. Do not assume the child is saying what you think is being said. We don’t really talk as much about what death means, but rather we think in terms of what the child thought about doing. Ask a child or adolescent, “Tell me more about what you were thinking. When do you have thoughts of suicide? What might help you feel better?” Pursue more specific questions about self-harm. “Did you ever think you wanted to hurt yourself? Tell me more about it. Did you ever think you wanted to do something to cause you to die? Did you ever try to do something to harm yourself or to cause you to die? Did you ever try to commit suicide? Did you think that there was something else you could do instead to feel better?”
It’s essential to help children or adolescents and their parents create a safety plan. This is based on the assessment. It must be relevant and meaningful and actionable, including an assured way that, if children think about acting on thoughts of self-harm, they will put themselves into a safer situation, talk with someone, and be with someone.
~ Cynthia R. Pfeffer, MD
CCPR: So, what is the next step following that assessment?
Dr. Pfeffer: It’s essential to help children or adolescents and their parents create a safety plan. This is based on the assessment. It must be relevant and meaningful and actionable, including an assured way that, if children think about acting on thoughts of self-harm, they will put themselves into a safer situation, talk with someone, and be with someone. It’s necessary to identify those helping people, but not someone who is difficult to reach. Children or adolescents need someone in proximity who is reliable, someone they are not afraid to tell about their suicidal thoughts or acts, and someone who is not afraid to help them. I have seen examples of an adolescent telling a peer, but subsequently the peer is afraid to tell a teacher or parent due to fear of creating upset or getting people in trouble. This plan should not only include peers, but also adults with whom the adolescent feels comfortable. In school, a guidance counselor or teacher may be helpful.
CCPR: How do you decide on the level of care needed for a patient to address suicidality?
Dr. Pfeffer: Prevention and intervention are guided by the assessment of risk factors. Level of care is a gradient, and you need to be familiar with what services are available in the community. All planning should include psychotherapy and consideration of treatment with medication. Outpatient care is most common. We need to work carefully on deciding how many times a week the child or adolescent will be seen, plan for work with the parents, and help the family cope. Because of expertise in assessing and treatment planning that could include use of medication, psychiatrists should be on the intervention team.
CCPR: How should we proceed if there has been a serious attempt at suicide?
Dr. Pfeffer: Because hospitalization enhances safety for an acutely suicidal child or adolescent, consider admission to a psychiatric inpatient setting. Psychiatric inpatient services are helpful in providing a comprehensive evaluation of risk factors and starting interventions such as medication, cognitive strategies, family therapy, and planning for outpatient safety strategies. Hospitalization is used to reduce suicidal ideation, symptoms of psychiatric disorders, and family conflicts, as well as to educate the child or adolescent and parents about maintaining safety and compliance with treatment. Psychiatric day hospital programs are also available in some communities. These may give relief from school stress. But because the child or adolescent goes home at the end of the day, it may expose the child or adolescent to situations that could precipitate suicidal ideation or acts. It is essential to have an effective safety plan for children or adolescents treated in less restrictive settings than a psychiatric inpatient hospital.
CCPR: Are there some resources we should be recommending to parents?
Dr. Pfeffer: There are several resources for families, including the American Academy of Child and Adolescent Psychiatry, American Foundation for Suicide Prevention, and American Association of Suicidality.
CCPR: Thank you for your time, Dr. Pfeffer.