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Suicidal behavior in children and adolescents: Evaluation and management
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Suicidal behavior in children and adolescents: Evaluation and management
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Aug 23, 2016.

INTRODUCTION — Suicidal behavior includes the spectrum from thoughts or ideas that revolve around suicide or death (suicidal ideation) through fatal completion of suicide [1,2]. Between these extremes are suicide threats and suicide attempts (potentially self-injurious action with a nonfatal outcome for which there is evidence that the individual intended to kill him or herself) [1]. Children and adolescents who present for medical attention with suicidal behavior require a variable amount of medical, social, and psychiatric intervention depending upon the seriousness of their intent, their underlying risk factors, and their emotional support system.

The evaluation and management of children and adolescents with suicidal ideation will be reviewed here. The epidemiology of and risk factors for childhood and adolescent suicide are discussed separately. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)

IDENTIFICATION OF SUICIDE RISK — Prevention of suicide involves identification of at-risk youth before suicidal behavior emerges. Clinicians play a central role in prevention since they are well positioned to identify and pursue early treatment for children and adolescents at-risk. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)

The American Association of Suicidology developed a mnemonic ("is path warm?") to help identify key warning signs for suicide [3,4]:

Ideation — Talking about or threatening to kill or hurt oneself; looking for ways to kill oneself; talking or writing about death, dying or suicide

Substance abuse — Increased substance use


Anxiety — Anxiety, agitation, or changes in sleep pattern

Trapped — Feeling like there is no way out


Withdrawal — Withdrawing from friends, family, and society



Mood changes

Screening in primary care — There is no evidence that routine screening for suicidal ideation in adolescent primary care patients reduces suicide attempts or mortality. Systematic reviews for the United States Preventive Services Task Force (USPSTF) have concluded that the evidence is insufficient to determine the benefits of screening for suicide risk in the general population of United States adolescents who do not have existing mental disorders or past histories of suicide attempts [5,6]. However, there is evidence that certain screens for suicidal risk will indeed identify suicidal adolescents [7,8], but whether that identification translates into improved outcomes has yet to be tested or proven.

The USPSTF clinical practice guideline for screening for suicide risk, as well as other USPSTF guidelines, can be accessed through the website for the Agency for Healthcare Research and Quality.

Asking about suicide — The basic means to identify at-risk youth is to simply ask about suicidal thoughts, intent, and risk factors as part of routine health care. The concern that talking or asking about suicide will initiate suicidal actions or ideation in a child or adolescent is not supported by evidence [9]. (See "Guidelines for adolescent preventive services", section on 'Screening'.)

The following risk factors for suicide should be included in adolescent health screening:


Alcohol or substance abuse

History of interpersonal violence or witnessing domestic violence as a child

Demonstrating that one is comfortable discussing suicide is an important element of an effective inquiry. Toward this end, the questions that are posed should be short, to the point, and asked in a non-judgmental manner in developmentally appropriate language [10]. Sample questions include:

Do you ever think about dying? How often?

What do you think happens when you die?

Have you ever wished you were dead?

Do you ever think the world would be better off if you were dead? Do you think life would be easier for your family and friends if you were dead? Have you ever thought of what would have to happen for your life to end?

Have you had thoughts about hurting yourself? Killing yourself?

Have you ever tried to kill yourself?

If the child or adolescent begins talking about suicidal thoughts, the lines of communication must be kept open. This can be facilitated through active listening, patience, maintenance of a calm demeanor, and neither minimizing the patient's concerns, nor reacting with disapproval. The natural tendency to be reassuring and optimistic must be inhibited. Attempts to talk the child or adolescent out of suicide should be avoided, as should discussions of whether suicide is right or wrong. In addition, confidentiality should not be promised since it cannot be maintained under these circumstances. (See "Confidentiality in adolescent health care", section on 'Suicidal ideation or attempt'.)

Risk assessment — Once a child or adolescent has disclosed suicidal ideation, prompt assessment of suicidal risk is in order. Risk for suicide should be considered imminent in patients who report an active plan or intent and have access to lethal means. The clearer the intent, the higher the risk, particularly in the context of disinhibition (eg, impulsivity or intoxication) and access to lethal means.

A brief focused screening tool may have some value in identifying risk for suicidality when administered by non-mental health clinicians. The combination of inquiring about current suicidal behavior, past suicidal ideation, past self-destructive behavior, and current stressors yielded the highest sensitivity and identified 98 percent of children at risk for suicide in comparison to the assessment performed by trained mental health clinicians [11].

A thorough risk assessment includes evaluation of:

The content, nature, and chronicity of the suicidal thoughts (table 1)

The existence and details of a suicide plan (table 1)

Access to the means described in the plan (table 1)

Other factors related to motivation, emotional/behavioral regulation, support systems and stressors (table 2)

Risk assessment information should be obtained from several sources, including the child or adolescent, parents or guardians, school reports, therapists and behavioral staff, and other individuals who are close to the child or adolescent [2]. This is because the child or adolescent may have reason to provide inaccurate information (eg, to avoid hospitalization). Because children may not be able to accurately assess lethality, suicide risk assessment in children should be based upon the child's perception of lethality rather than the objective lethality of the suicidal act [10,12].

Intervention/referral — When a child or adolescent is in an acute suicidal crisis, the focus of the intervention is to keep him or her safe until the suicidal state diminishes or abates. This usually involves working with the family or other supportive individuals who can address safety concerns (eg, remove access to means) and are willing to stay with the child or adolescent at all times.

Treatment options may include hospitalization, medication, more frequent psychological intervention, mobilizing supports, access to crisis intervention services, and no-suicide contracts [13]. The level of intervention depends upon the level of suicide risk, available support, and the ability of the child or adolescent to join with those who seek to keep him or her safe. (See 'Risk assessment' above.)

Immediate psychiatric evaluation (through the emergency department or psychiatry crisis clinic) and/or hospitalization is indicated when there is an imminent risk of suicide (eg, an active plan or intent without solid support or psychiatric or psychological intervention already in place to maintain safety) [10,14-17].

Referral to a mental health professional is warranted if the risk is not imminent. However, consideration of the availability of the mental health professional is important, so as to avoid delays in needed treatment.

The confidentiality of the adolescent who is at risk to harm him- or herself must be breached in deference to his or her safety [14]. An adolescent who agrees to a "no-suicide" contract is still at very high risk; this agreement does not protect the patient or the clinician. The agreement to a "no-suicide" contract should not be substituted for thorough evaluation, therapeutic interaction, or sound clinical judgment [18,19], particularly in an impulsive adolescent. The efficacy of such contracts has not been proven, although they may help in fostering a therapeutic alliance [18,20,21].

EMERGENCY EVALUATION — Children and adolescents with suicidal behavior are typically evaluated in an emergency department. Medical stabilization is the first priority for those who have attempted suicide. The manner in which children and adolescents with suicidal behavior and their families are treated by the emergency department staff may affect compliance with follow-up care [22]. The importance of treatment should be stressed by both the emergency department and crisis team staff [2]. (See 'Management' below.)

Children and adolescents with suicidal behavior should have one-to-one attention until the seriousness of their intent is evaluated by the appropriate mental health or emergency department personnel. Potentially harmful medical supplies and equipment should be removed from the examination room where the patient is to be evaluated [10]. To discourage elopement, a hospital gown should be provided to the patient and his or her clothing should be stored separately [23].

The unique challenge of caring for children and adolescents with suicidal behavior requires careful deliberation and planning for emergency department staff. Emergency departments may need to review their care system and modify their physical structure to provide a safe and contained environment for these patients [24]. Potential areas of modification include: more mental health training, better access to mental health records, the development of crisis plans for adolescents at risk, and provision of additional staff (eg, security and other personnel who play a role in observation of the at-risk patient).

History and examination — The important aspects of the history that should be included in evaluation of the child or adolescent with suicidal behavior are discussed in the psychiatric evaluation. (See 'Psychiatric evaluation' below.)

The physical examination should be performed with attention to vital signs, level of consciousness and orientation, and manifestations of toxidromes [23]. In addition, signs of previous suicide attempts (scars from cutting, bruises from hanging), physical or sexual abuse (characteristic bruising patterns, genital trauma) (table 3), substance abuse (track marks from intravenous drug use, nosebleeds or perioral blisters from inhalant use), and organic disease (eg, thyroid disease) should be sought [23]. (See "Approach to the child with occult toxic exposure" and "Physical child abuse: Recognition" and "Evaluation of sexual abuse in children and adolescents".)

Laboratory evaluation — The laboratory evaluation of the child or adolescent with suicidal behavior should be individualized according to the circumstances of the ideation or attempt and the clinical risk assessment for concerns of illicit drug use and confounding medical problems, such as pregnancy and presence of sexually transmitted infections. Studies to be considered include the following [23], which are generally required by hospitals before they accept patients for admission:

Toxicology screening, particularly for aspirin, acetaminophen, tricyclic antidepressants, and illicit drugs (see "Testing for drugs of abuse (DOA)")

Pregnancy test in girls

Quantitative drug or alcohol screening if the initial toxicology screen is positive

Tests for general medical causes of psychiatric conditions (eg, thyroid disease, inflammatory bowel disease, systemic lupus erythematosus, or Wilson disease) [25,26] (see appropriate topic reviews)

Psychiatric evaluation — Psychiatric evaluation should proceed after the patient is medically stable. The goals of the psychiatric evaluation include [2]:

Determination of the risk of suicide completion or subsequent attempt

Identification of predisposing and precipitating factors that can be treated or modified

The psychiatric evaluation should be performed by a clinician who has specialized training and experience in the psychiatric problems of children and adolescents. In some situations (ie, if a person with such training is not available), it may be necessary for an emergency department clinician to perform the initial evaluation to determine whether the patient should be transferred to another facility for a formal psychiatric evaluation. The information used in the evaluation should be gathered from several sources, including the child or adolescent, parents or guardians, school reports, previous psychiatric evaluation or assessments, and any other individuals who are close to the child [2]. This is because the child or adolescent may have reason to providing inaccurate information (eg, to avoid hospitalization).

Three main areas should be addressed when evaluating the seriousness of suicidality and the risk for future attempts or completion. These areas are discussed in detail above and include suicidal ideation, plan, and intent (the balance between the wish to live and the wish to die). Information regarding underlying psychiatric or medical diagnoses and the inciting event also is important when assessing suicide risk [2]. The use of the "MALPRACTICE" mnemonic can help to ensure that all of these areas are addressed (table 4) [16]. (See 'Risk assessment' above.)

Screening — Different instruments are available to screen for suicidal ideation and behavior [7], but it is not known if screening improves outcomes.

The Ask Suicide-Screening Questions is a four item instrument that clinicians can administer to screen for risk of suicide in patients who present to pediatric emergency departments with psychiatric or general medical complaints (form 1) [8]. The four items are:

In the past few weeks, have you wished you were dead?

In the past few weeks, have you felt that you or your family would be better off if you were dead?

In the past week, have you been having thoughts about killing yourself?

Have you ever tried to kill yourself?

Answering yes to at least one question constitutes a positive screen that should trigger a more extensive evaluation of the patient’s risk for suicide.

A cross-sectional study in patients aged 10 to 21 years who presented to pediatric emergency departments with psychiatric (n = 180) or general medical (n = 344) problems found that the Ask Suicide-Screening Questions had good psychometric properties [8]. Sensitivity was 97 percent and specificity 88 percent. In psychiatric patients, the positive and negative predictive values were 71 and 97 percent; in general medical patients, positive and negative predictive values were 39 and 100 percent. A limitation of the study was that it was cross-sectional rather than assessing true predictive ability.

By contrast, a systematic review found that two other screening instruments for suicidal ideation or behavior in high risk adolescents performed poorly [5].

MANAGEMENT — Based upon a review of randomized trials, there are several principles to bear in mind when managing suicidal children and adolescents [27]:

Most effective interventions for reducing suicidal ideation and preventing recurrence of suicide attempts address family interactions or increase nonfamilial support

Better outcomes can be achieved with more treatment sessions (eg, 10 or more)

Targeting alcohol and substance abuse when clinically indicated

Discussing motivation for treatment can be helpful

When suicidal crises occur, initiating treatment quickly (eg, within one week) and at a greater intensity (eg, multiple treatment sessions per week) may be helpful

Treatment administered by multiple clinicians should be coordinated

Medical stabilization — Medical stabilization of the patient who has attempted suicide is the first priority. The appropriate surgical service should be contacted for management of trauma. Patients whose attempt involved drug ingestion should undergo decontamination and receive antidotes as indicated. (See "Classification of trauma in children" and "Management of acetaminophen (paracetamol) poisoning in children and adolescents" and "Salicylate poisoning in children and adolescents" and "Gastrointestinal decontamination of the poisoned patient".)

Disposition — The disposition of the suicidal child or adolescent from the emergency department or medical care depends upon the immediate risk of suicide [10]. Children and adolescents should not be discharged from medical care until their account of events has been verified by their caregiver(s) [2].

Hospitalization — Psychiatric hospitalization for evaluation and initiation of therapy is nearly always indicated for children and adolescents with immediate high risk of suicide [2]. Individuals at immediate high risk of suicide include [23]:

Those who have used high lethality methods or taken steps to avoid detection

Those with psychiatric disorders

Those with current intoxication or history of substance abuse

Those with inability to develop trusting relationships with medical clinicians

Those with poor social support

Hospitalization for such individuals is the standard of care, although it has not been proven to be effective in preventing subsequent suicide [2].

While awaiting hospitalization, patients should be kept in a private room, with all sources of potential harm removed. Family may be present if the patient desires. A staff member should be assigned to stay with the patient at all times. Transfer of the patient should take place by ambulance, and the paramedics must be aware of the suicide risk. Restraints should only be used if the patient is actively seeking ways to harm self or others, although the proper use of restraints should be part of the educational curriculum for emergency department clinical staff [28]. The use of pharmacologic agents to sedate an aggressive or out of control adolescent should be undertaken with caution because of the potential side effects of these agents [29]. Inpatient treatment should continue until the mental state or level of suicidality has stabilized [2].

Involuntary hospitalization — It may be necessary to consider involuntary hospitalization if the parents or legal guardian of the child are not present and/or are not in agreement with the clinician's plans for hospitalization [16]. The mechanisms for hospitalization of a person who will not or cannot sign themselves into a hospital vary from state to state. Most states require that the patient be a danger to self or others and/or substantially unable to care for him or herself.

Patients who are admitted against their will, or the will of their guardians, maintain the autonomy to consent for treatment [16]. The only medications that can be administered without their consent, or the consent of their guardians, are those that are necessary for stabilization during a crisis.

Outpatient treatment — Outpatient therapy is usually the best option for lower risk individuals (eg, patients who are medically stable and do not have a specific plan and intent to kill themselves) [23,30]. Outpatient therapy requires the involvement of the family and their willingness to stay with the patient continuously [2,16,17]. All lethal means of suicide, particularly firearms and medications, should be made unavailable to patients. The acute crises that precipitated the event must be addressed and attempts made to resolve them. Patients and parents should be warned about the dangerous disinhibiting effects of alcohol and other drugs [2]. Psychiatric follow-up must be secured within 48 hours and patients and family members should be instructed to return to the emergency department if patients decompensate.

Intensive home therapy — Intensive home therapy may possibly be an option for some patients who need crisis stabilization [30].    

Psychotherapy — Psychotherapy can reduce self-harm in adolescents. A systematic review compared psychotherapy with usual care in adolescents (n >2000) who self-harmed at least once [31]. The active treatments included many types of psychotherapy (often combined with usual care), and self-harm ranged from nonsuicidal self-injury to suicide attempts. A pooled analysis found that subsequent self-harm occurred in fewer patients who received psychotherapy than usual care alone (28 versus 33 percent). However, heterogeneity across studies was high. Therapies with the largest clinical effect included cognitive-behavioral therapy, dialectical behavioral therapy, and mentalization based therapy. In addition, reduction of self-harm was observed in trials with treatment that lasted more than one session, and in those with a large family component, but not in trials with a small family component.  

Cognitive-behavioral therapy — A trial involving both acute and maintenance treatment compared usual care plus cognitive-behavioral therapy (CBT) with usual care alone in 36 adolescents with suicidal ideation or behavior and substance use disorders [32]. CBT was augmented with family therapy and motivational interviewing. At the assessment 18 months post-enrollment, usual care plus psychotherapy was superior to usual care alone with regard to suicide attempts (5 versus 35 percent), hospitalization (16 versus 53 percent), and arrest (5 versus 41 percent).

Dialectical behavior therapy — Dialectical behavior therapy appears to reduce adolescent self-harm. A 19-week, open-label randomized trial compared dialectical behavior therapy with usual care in adolescent outpatients with repetitive self-harm (n = 77) [33]. Dialectical behavior therapy included weekly sessions of individual therapy, weekly multifamily group sessions addressing skill deficits, and family therapy sessions as indicated. Usual care included at least one weekly individual therapy session (eg, psychodynamically-oriented therapy or cognitive-behavioral therapy). Pharmacotherapy was allowed in both groups. Reduction of self-harm incidents as well as depression was greater with dialectical behavior therapy than usual care. However, the number of treatment sessions was greater with dialectical behavior therapy, and the therapists administering dialectical behavior therapy required extensive training and supervision.

Family therapy — Open label randomized trials indicate that family therapy (often combined with other treatment) can reduce adolescent suicidal ideation and behavior. As an example:

A four-week trial compared outpatient usual care plus family therapy with usual care alone in 48 adolescents with unipolar major depression who had at least one episode of self-injurious behavior (eg, cutting or overdosing) or had verbalized thoughts or threats of suicide [34]. Family therapy (four sessions, each lasting two hours) was provided in a single family format to only the parents, and focused upon education about self-injurious behavior and adolescent development, and strategies to manage stress and family conflicts and promote adolescent self esteem and family harmony. Reduction of suicidal ideation and behavior and other psychiatric symptoms was greater in patients whose parents received family therapy, and the benefits persisted at the six month follow-up.

A 12-week trial compared attachment-based family therapy (average of 10 sessions) to usual clinical management (average of 3 sessions) in 66 mostly poor and minority adolescents with suicidal ideation [35]. Remission of suicidal ideation occurred in more patients treated with family therapy than usual care (87 versus 52 percent), and the benefits persisted at follow-up assessments 12 weeks after the study ended.  

Mentalization based therapy — Mentalization based therapy appears to reduce adolescent self-harm. A one-year randomized trial compared mentalization based therapy with usual care (mental health services) in adolescents (n = 80) who presented with self-harm [36]. Mentalization based therapy is a form of psychodynamic psychotherapy that focuses upon impulsivity and affect regulation; treatment was administered in weekly individual sessions and monthly family therapy. Nearly all of the adolescents suffered from depressive syndromes and most also suffered from borderline personality disorder. Subsequent self-harm occurred in fewer adolescents who received mentalization based therapy than controls (43 versus 68 percent). In addition, reduction of depressive and borderline symptoms was greater with active treatment. Mentalization improved self-harm outcome by improving the quality of attachment between adolescents and their parents, and by improving the ability to mentalize, that is, to conceptualize actions in terms of thoughts and feelings.

Pharmacotherapy — The emergent administration of antidepressants has no role in the acute management of the suicidal adolescent or child. However, many pediatric patients hospitalized for suicidality are treated with pharmacotherapy for an underlying psychiatric disorder (eg, unipolar major depression). Selective serotonin reuptake inhibitors are often used, based upon efficacy and tolerability. All medications that are prescribed for the suicidal child must be monitored and any changes in behavior or side effects must be reported immediately [2]. Although there is some concern that antidepressants may increase the risk of suicidality in pediatric patients, this remains an area of significant controversy, and the consensus among most mental health specialists is that the benefits of antidepressant therapy outweigh the risks. (See "Pediatric unipolar depression and pharmacotherapy: Choosing a medication" and "Pediatric unipolar depression and pharmacotherapy: General principles" and "Effect of antidepressants on suicide risk in children and adolescents".)

SCHOOL BASED PREVENTION — Several randomized trials indicate that prevention programs that are administered in schools can reduce suicide attempts in students [37]. As an example, one open label, school based trial in adolescents (n >8000 analyzed) compared a program focused upon youth awareness with two other interventions, gatekeeper training and screening, as well as a control condition [38,39]. The youth awareness program trained students to recognize depression and suicidality in themselves and other students, and encouraged adaptive coping and help-seeking; the program included three hours of role play sessions, two hours of interactive lectures, and a 32 page booklet that students could take home. Gatekeeper training taught teachers to recognize suicidality in students. Screening of students was conducted by health professionals, who referred students at risk for suicide to clinical services. During follow-up lasting 12 months, fewer suicide attempts occurred in the youth awareness program than the control condition (0.7 versus 1.5 percent of adolescents). By contrast, the number of suicide attempts was comparable in the gatekeeper, screening, and control groups.  

COMMUNITY BASED PREVENTION — Limited evidence suggests that short term community based interventions may temporarily reduce suicide attempts and mortality in youth. One such community program in the United States that is widely used to prevent youth suicide is the Garrett Lee Smith Memorial Suicide Prevention Program. This short term program includes various approaches, for example, training individuals such as teachers and primary care physicians to identify youth at risk for suicide and to refer them for help (gate keeper training). The program also includes education, screening, and crisis hotlines. A retrospective observational study examined suicide attempts in youth (age 16 to 23 years of age; n = approximately 57,000) living in communities that implemented the program, and youth (n = approximately 84,000) living in communities that did not implement the program (control group) [40]. The active intervention was associated with fewer suicide attempts in the first year after implementation of the program (5 fewer attempts per 1000 youth, for an estimated total of more than 79,000 attempts nationwide). However, the rate of suicide attempts in the two groups beyond one year was comparable. Similarly, suicide mortality in the active intervention group was reduced in the first year after implementing the program (1 less death per 100,000 youth, for an estimated total of 427 deaths nationwide); however, this benefit was not sustained beyond one year [41]. The findings suggest that suicide prevention requires continuous efforts over time.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: Depression in children and adolescents (Beyond the Basics)" and "Patient education: Depression treatment options for children and adolescents (Beyond the Basics)")

SUMMARY — Pediatric health care providers can take the following actions to prevent suicide in children and adolescents [14,42]:

Know the risk factors for suicide in children and adolescents. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)

Recognize the clinical presentations of and differential diagnoses for psychiatric disorders in children and adolescents. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)

Take active steps to identify children and adolescents at risk for suicide (eg, ask about suicidal thoughts and suicide risk factors during routine health care visits) and pursue early treatment for at-risk youth.

Provide anticipatory guidance regarding the risks of access to firearms and other lethal means (eg, drugs, prescription medications).

Be familiar with community, state, and national resources that are concerned with youth suicide (table 5A-B), particularly local individuals and agencies that accept referrals in times of crisis.

Provide support in times of crisis.

Consult with mental health colleagues and coordinate care.

Advocate eliminating barriers in public and private insurance programs for provision of quality mental health and substance use disorder treatments.

Implement strategies to reduce the stigma associated with depression, substance abuse, and suicidal behavior and with seeking help for such problems.

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