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Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident August/September 2013
A 14-year-old boy is brought to the ED with a wrist laceration. Accident or suicide attempt?
Self-harm is the third leading cause of death in this age category behind violence and motor vehicle accidents. One nationally representative sample suggests 7% of U.S. teens have attempted suicide in the last year, and 2% have made attempts serious enough to require medical attention.
What features of history can help evaluate for it? What are meaningful screening questions for adolescent suicide? The following is a rank-ordered list of identified odds ratios of suicide.[1,2]
Previous attempt: 67.4
Eating disorder: 14.2
Any mood disorder: 9.8
Cluster B personality disorder: 8.5
Any psychiatric disorder: 9.4
Substance abuse: 7.2
Sleep ≤4 hours: 6.5
Loss in the family: 5
Conduct disorder: 4.6
Family history of suicide: 4
Anxiety disorder: 2.8
The patient interview is ideally done privately (e.g., away from parents and out of a hallway). Even with ideal conditions, deception is likely with many of the questions, so most of these should be considered “screening” questions: “Yes” is significant while “No” doesn’t rule it out.
“Previous attempt” is the most important one on the list. While there is a paucity of evidence on suicide in general and teen suicide specifically, this theme seems to come up again and again and it far outweighs the other factors. This is the most important risk factor. It is also important to note the type of attempt; methods are often repeated, so highly lethal methods (hanging, jumping, shooting) should be of particular concern.
Psychological stress of any kind seems to be another broad category that puts patients at risk: abuse, neglect, death in the family, homosexuality in an unsupportive context and psychiatric disorders (especially eating disorders). Alcohol use is quite common amongst teens (46% used alcohol in the past 30 days), and also confers a rather high risk.
In addition to these, there are the traditional factors identified in adults which carry over. Junhke has adapted the SADPERSONS pneumonic to child and adolescent applications: Sex (male), Age (old teens > young teens), Depressed, Previous attempt, Ethanol/drug use, Rational thinking loss, Social support lacking, Organized plan, Negligent parenting/family stress, School problems.
Suicidality is surprisingly common amongst teenagers and is an important issue in the emergency department. In general, the list of risk factors is similar to adults, but one should not forget about challenges and risks specific to teenage years like family stress, substance use, sleep and eating disorders.
1. Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006;47(3-4):372-94.
2. Fitzgerald CT, Messias M, Buysse DJ. Teen Sleep and Suicidality: Results from the Youth Risk Behavior Surveys of 2007 and 2009. J Clin Sleep Med. 2011;7(4): 351–356.
3. Suicide Trends Among Youths and Young Adults Aged 10-24 Years – United States, 1990-2004. CDC Morbidity and Mortality Weekly Report. 2007;56(35):905-908. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a2.htm.
4. Junhke GA. The adapted-SAD PERSONS: a suicide assessment scale designed for use with children. Elementary School Guidance & Counseling. 1996; 30:4.