Screening teens for suicide risk is among the recommendations in a new clinical report from the American Academy of Pediatrics Committee on Adolescence.

Suicide is now the second-leading cause of death for teens aged 15-19 years, having surpassed homicide since 2007, when the last report on adolescent suicide was published by the AAP ( Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420 ). Excessive Internet use and cyberbullying are considered to be risk factors for suicide.

In addition to screening for suicide risk, the AAP advises screening for mood disorders, and for substance abuse and dependence. “Ask about emotional difficulties and use of drugs and alcohol, identify lack of developmental progress, and estimate level of distress, impairment of functioning, and level of danger to self and others,” the committee members wrote. The report offers several examples of questions to use for screening during the visit or interview.

“Self-report scales may be helpful, but they do not substitute for pediatricians asking teens directly (and sensitively) about mood disorders, substance use, suicidal and self-harmful thoughts, behaviors, stress, and distress,” Benjamin Shain, MD, PhD, the report’s author and a member of the AAP Committee on Adolescence, said in an interview. “Since ‘black box’ warning labels were added to antidepressants in 2004, new, population-based research has indicated that the benefits of these medications outweigh the risks for many patients. Physicians should not shy away from prescribing these medications when they are clinically indicated.”

Risk factors

A significant risk factor for suicide is involvement in bullying, whether the teen is the victim, the bully, or both, with the latter – bully victims – at the highest risk. The increased risk for suicidal thoughts or attempts extends to involvement with cyberbullying, in addition to physical, social, and verbal bullying, according to the committee members.

Results of a meta-analysis indicate girls who are victims or perpetrators of bullying are at higher risk for suicidal thoughts or attempts regardless of how common or rare the bullying is, whereas boys had an increased risk only when the bullying was frequent. Bullying as early as age 8 years was associated with attempted and completed suicides in adolescence, according to one study.

In a 2013 survey of U.S. high school students, 24% of girls and 16% of boys reported being bullied on school property in the past year. Cyberbullying occurred among 21% of the girls and 9% of the boys.

Teens reporting video game or Internet use for at least 5 hours a day were at higher risk for suicidal thoughts, suicide attempts, and depression, the committee noted. An additional wrinkle of Internet use is that teens may read about others’ suicides, which increases their own risk, or they may seek out pro-suicide websites.

“Suicide-related searches were found to be associated with completed suicides among young adults,” the report noted.

The good news is that major search engines prioritize institutional sites and mental health support sites in response to searches for “suicide,” Dr. Shain said.

“Despite the negatives, there is evidence that the Internet and electronic media, in general, provide a large amount of support, including keeping teens connected to their friends, family, teachers, and others, and also providing entertainment and valuable or interesting information,” Dr. Shain noted. “The Internet may be particularly useful for distressed teens.”

“More than 90% of adolescent suicide victims met criteria for a psychiatric disorder before their death,” the report noted. “Immediate risk factors include agitation, intoxication, and a recent stressful life event.”

Take action to help at-risk teens

The committee advises taking the following steps to assist at-risk teens:

In routine history taking, ask questions about mood disorders, use of drugs and alcohol, suicidal thoughts, bullying, sexual orientation, and other risk factors associated with suicide throughout adolescence.

Develop working relationships with emergency departments and colleagues in child and adolescent psychiatry, clinical psychology, and other mental health professions to optimally evaluate and manage the care of adolescents who are at risk for suicide.

Become familiar with local, state, and national resources that are concerned with treatment of psychopathology and suicide prevention in youth, including local hospitals with psychiatric units, mental health agencies, family and children’s services, crisis hotlines, and crisis intervention centers.

Consider additional training and ongoing education in diagnosing and managing adolescent mood disorders, especially if you practice in an underserved area.

During routine evaluations and where consistent with state law, ask whether firearms are kept in the home and discuss with parents the increased risk of adolescent suicide with the presence of firearms. Specifically for adolescents at risk for suicide, advise parents to remove guns and ammunition from the house and secure supplies of prescription and over-the-counter medications.

Learn about the benefits and risks of antidepressant medications, and how to monitor depressed patients. Educate the family regarding the following warning signs that warrant contacting you: new or more frequent thoughts of wanting to die; self-destructive behavior; signs of increased anxiety/panic, agitation, aggressiveness, impulsivity, insomnia or irritability; new or more involuntary restlessness (akathisia), such as pacing or fidgeting; extreme degree of elation or energy; fast, driven speech; or new onset of unrealistic plans or goals.

Risk factors for suicide

Fixed risk factors

• Family history of suicide or suicide attempts.

• History of adoption.

• Male gender.

• Parental mental health problems.

• Lesbian, gay, bisexual, or questioning sexual orientation.

• Transgender identification.

• A history of physical or sexual abuse.

• Previous suicide attempt.

Social/environmental risk factors

• Bullying.

• Impaired parent-child relationship.

• Living outside of the home (homeless or in a corrections facility or group home).

• Difficulties in school.

• Neither working nor attending school.

• Social isolation.

• Presence of stressful life events, such as legal or romantic difficulties or an argument with a parent.

• An unsupported social environment for LGBTQ adolescents.

Personal mental health problems

• Sleep disturbances.

• Depression.

• Bipolar disorder.

• Substance intoxication and substance use disorders.

• Psychosis.

• Posttraumatic stress disorder.

• Panic attacks.

• A history of aggression.

• Impulsivity.

• Severe anger.

• Pathologic Internet use.

Source: Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420.


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