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. Author manuscript; available in PMC: 2019 Nov 29.
Published in final edited form as: Cogn Behav Pract. 2018 Jun 5;25(4):460–472. doi: 10.1016/j.cbpra.2018.04.001

Assessment and Management of Suicide Risk in Children and Adolescents

Jeremy W Pettit 1, Victor Buitron 2, Kelly L Green 3
PMCID: PMC6884133  NIHMSID: NIHMS1522160  PMID: 31787833

Abstract

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.

Keywords: suicide, suicidal, children, adolescents, assessment, safety planning

Assessment and management of suicide risk are among the most daunting tasks faced by mental health clinicians who work with children and adolescents (hereon referred to as youth). Mental health clinicians report feeling inadequately trained to handle suicide risk assessment (Dexter-Mazza & Freeman, 2003; Feldman & Freedenthal, 2006) and identify client suicidal behaviors as one of the most stressful and impactful aspects of their job (Deutsch, 1984; McAdams & Foster, 2000). When we give workshops on assessment and management of suicide risk in youth, we commonly hear from audience members that available resources are perceived in Goldilocks’ terms: either too little, meaning insufficient guidance on how to translate clinical and research findings into practice, or too much, meaning exhaustive protocols that are challenging to implement in practice settings.

In the present article, we aim to address assessment and management of suicide risk in youth at a level of detail that gets closer to a “just right” amount for practicing mental health clinicians. In any single article, it is impossible to cover adequately the entire empirical and clinical literatures relevant to suicidal behaviors in youth. For in-depth coverage of these literatures, we refer readers to several excellent books (e.g., Berman, Jobes, & Silverman, 2006; Brent, Poling, & Goldtein, 2011; King, Foster, & Rogalski, 2013), reviews (Bridge, Goldstein, & Brent, 2006; King & Merchant, 2008; Waldrop et al., 2007), task force recommendations (LeFevre & Force, 2014; Shaffer et al., 2001), and recent empirical studies (e.g., Asarnow, McArthur, Hughes, Barbery, & Berk, 2012; Asarnow, Hughes, Babeva, & Sugar, 2017; Hughes & Asarnow, 2013; Jakobsen, Larsen, & Horwood, 2017). We also strongly encourage readers to obtain training in evidence-based assessment of suicide risk by attending relevant workshops and continuing education offerings (Pisani, Cross, & Gould, 2011).

Our purpose in writing this article is to concisely present concrete, easy-to-implement recommendations for assessing and managing suicidal behaviors in youth. The recommendations we present draw from the available empirical and clinical literatures, and are optimally suited for outpatient treatment settings and school settings, although they could be adapted for use in other settings, such as hospitals or emergency departments. We begin by presenting recommendations for suicide risk assessment and risk designation, then present safety planning as a brief intervention and risk management strategy. We conclude with a case illustration.

Suicide Risk Assessment and Designation in Youth

Overview

Clinicians are sometimes reluctant to broach the topic of suicide with youth due to concerns that talking about suicide might inadvertently create a risk that was not already present or might damage rapport with a client. Compelling data demonstrate that suicide risk screening or assessment does not enhance risk in youth, and may even lead to reductions in distress among youth who are experiencing thoughts of suicide (e.g., Gould et al., 2005). In our experience, clinicians can maintain, and sometimes even enhance, rapport through skilled assessment of suicidal thoughts and behaviors. Skilled assessment assures youth that clinicians are genuinely concerned about their well-being, supportive of their autonomy, and willing to engage in open and empathic dialogue about sensitive topics.

Skilled suicide risk assessment begins with providing an explanation of the importance of the topic and asking for permission to proceed (Brent et al., 2011). When introducing the topic, normalizing the experience of suicidal thoughts and behavior and discussing them in a matter-of-fact manner lowers defenses and leads to more open disclosure. Asking permission further lowers defenses and conveys respect for youths’ autonomy. For example, we often begin suicide risk assessment with a statement like the following:

“As we work together, my number one priority is your safety and well-being. Sometimes when people are feeling upset or going through a difficult time, they have thoughts about hurting themselves or wanting to die. Is it okay if I ask you some questions about those types of thoughts?”

If a youth grants permission, the clinician has an open door to inquire about suicidal thoughts and behaviors. If a youth does not grant permission, the clinician should explore the youth's concerns about discussing the topic (e.g., concerns it will lead to hospitalization) and then return to the importance of the topic. An open and empathic dialogue about youths’ concerns often leads to a greater willingness to disclose suicidal thoughts and behaviors. Nevertheless, suicide risk assessment is not optional. If a youth continues to refuse to answer questions about suicidal thoughts and behaviors, the clinician should convey that risk assessment is their ethical and professional responsibility, and that they may have to take steps to ensure the youth's safety if they are unable to assess risk, including hospitalization. Although we typically find caregivers are open to discussing their children’s suicidal thoughts and behaviors, clinicians can use the same approach of explaining the importance of the topic, asking permission, addressing concerns, and then returning to risk assessment when meeting with caregivers.

A common concern of both clinicians and youth is limits to confidentiality. Whether or not youths express concern about limits to confidentiality, clinicians must discuss it prior to inquiring about suicidal thoughts and behaviors. We frequently hear concern from clinicians that explicitly discussing limits to confidentiality prior to suicide risk assessment might result in youths being less willing to disclose suicidal thoughts and behaviors. The concern is valid; however, for reasons both ethical and therapeutic, it is important to make sure youths understand limits to confidentiality prior to assessing suicide risk. The potential cost of ruptured trust and rapport, especially in the context of an ongoing treatment relationship, outweighs the potential benefit of information obtained from individuals who do not understand the limits of confidentiality. Youths should not be surprised or feel “duped” in the event that clinicians break confidentiality. We broach the subject of limits to confidentiality with a statement like the following:

“Before we go any further, I want you to know that what we talk about today will be private and I will not talk about it with other people unless it is necessary to keep you safe. If I have concerns for your safety, I may need to speak with other people about that, including your parents. However, I will only share information that is necessary to keep you safe – I will not share other things we discuss.”

Once the youth grants permission and the clinician discusses limits to confidentiality, the clinician should proceed to ask about suicidal thoughts and behaviors. Clinicians should elicit information relevant to suicide risk from as many sources as possible, at minimum from youths and their primary caregivers (Goldston & Compton, 2007; Shaffer et al., 2001). Whenever possible, we recommend clinicians arrange sessions in a way that allows them to elicit information independently from each informant by speaking with the youth alone and caregivers alone. This is because youths may be more comfortable discussing sensitive topics like suicidal thoughts and behaviors without caregivers present, and thus more likely to disclose such thoughts and behaviors. Similarly, caregivers may report relevant information that youths do not, including prior histories of suicidal behaviors. When discrepancies exist between informants, as is often the case (Prinstein, Nock, Spirito, & Grapentine, 2001), clinicians should seek clarification with each informant. Given the immense consequences of a false negative (i.e., suicide attempt or death), we recommend clinicians consider endorsement of suicidal thoughts or behaviors from any source (i.e., youth or caregiver) a “positive” when designating risk, unless there is compelling evidence to the contrary.

What to Look for?

Risk assessment and designation should directly inform action steps. Many variables have been identified as risk factors and warning signs for suicide attempts and suicide in youth (for reviews, see Bridge et al., 2006; Esposito-Smythers, Weismoore, Zimmerman, & Spirito, 2014; Shaffer et al., 2001). Although these variables are often informative in developing case conceptualizations and identifying treatment targets, it can be overwhelming (not to mention impractical) to try to assess all known risk factors and integrate them into a risk designation. Out of necessity, the risk assessment and designation algorithm we present focuses on a small subset of variables that are most directly implicated in short-term risk of suicide attempt. The algorithm we present draws upon empirical literature whenever possible. In the absence of empirical literature, we draw on clinical experience and judgment. A large number of measures are available to assess the variables listed in the algorithm (for reviews, see Goldston, 2003; Goldston & Compton, 2007). We recommend the Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011) or the Self-Injurious Thoughts and Behaviors Interview (SITBI; Nock, Holmberg, Photos, & Michel, 2007) because clinicians can administer them quickly, there is ample support for their reliability and validity, and they are in the public domain.

We present an algorithm for determining acute suicide risk in youth in Figure 1. When determining risk, it is essential to recognize the distinction between risk status (i.e., chronic risk level) and risk state (i.e., acute risk level; Pisani, Murrie, & Silverman, 2016; Wortzel, Homaifar, Matarazzo, & Brenner, 2014). Designation of risk state must take into account youths’ chronic risk level. Risk status, or chronic risk level, is determined by youths’ histories of suicidal and nonsuicidal self-injurious behaviors, as we elaborate below.

FIGURE 1.

FIGURE 1

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Algorithm for assessing acute suicide risk.

Elevated Chronic Risk: Prior History of Suicide Attempt or Nonsuicidal Self-Harm

The initial decision point in the algorithm is the presence versus absence of a prior history of nonfatal suicide attempt or nonsuicidal self-injury (NSSI). A nonfatal suicide attempt is defined as a behavior that, at minimum, has the potential for injury wherein the individual has any nonzero intent to die as a result of the behavior (Crosby, Ortega, & Melanson, 2011). NSSI is defined as a behavior that, at minimum, has the potential for injury, but wherein there is no evidence of explicit or implicit intent to die as a result of the behavior (Crosby et al., 2011). A prior suicide attempt is the single strongest predictor of suicide, especially in boys (Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Marttunen, Aro, & Lonnqvist, 1992; Shaffer et al., 1996). A prior suicide attempt is associated with an over 30-fold increase in the rate of suicide in boys and a 3-fold increase in the rate of suicide in girls (Brent et al., 1999). A prior suicide attempt, the number of prior suicide attempts, and prior NSSI are also strong predictors of future nonfatal suicide attempts (Asarnow et al., 2011; Goldston et al., 1999; Prinstein et al., 2008; Wilkinson, Kelvin, Roberts, Dubicka, & Goodyer, 2011). Following a suicide attempt, the first year, especially the first 3 to 6 months, represents the highest-risk window for a reattempt (Goldston et al., 1999; Lewinsohn, Rohde, & Seeley, 1996). Clinicians must be vigilant in assessing and monitoring suicide risk during the year following an attempt, even if the youth appears to be “doing fine.”

Based on clear, replicated empirical demonstrations that youths with prior histories of suicide attempts or NSSIs are at elevated risk for future attempts, risk assessment and designation must prioritize these variables. When inquiring about suicidal thoughts and behaviors with youths, it is helpful to use open-ended questions and avoid using the word “suicide” because youths may differ in their understanding of the term. For example:

“Sometimes people think about hurting themselves or killing themselves when they are very upset. How many times have you tried to hurt yourself? How many times have you tried to kill yourself?”

This set of questions opens with a normalizing statement and then transitions to questions that assume youths may have already engaged in NSSI or made a nonfatal suicide attempt. This “gentle assumption” has been proposed to lead to fuller disclosure of past self-harm behavior than a simple yes or no question such as “Have you ever tried to kill yourself?” (Goldston & Compton, 2007; Shea, 1999). Clinicians should follow up affirmative responses to questions about prior NSSI or suicide attempts with probes to elicit details about the nature and frequency of these past behaviors. We also encourage clinicians to classify suicidal and self-harm behaviors using standard language and definitions, such as the CDC’s uniform definitions (Crosby et al., 2011), to facilitate clear communication among treatment providers.

Current thoughts of suicide.

The second decision point in the algorithm is the presence versus absence of current thoughts of suicide. When making risk designations, clinicians must view current suicidal thoughts in the context of youths’ chronic risk status. We present the algorithm for youth who have a prior history of suicide attempt and/or NSSI above the diagonal in Figure 1. These youth are at elevated chronic risk of suicide.

A large number of self- and interviewer-administered rating scales are available to assess current thoughts of suicide, including the C-SSRS and SITBI (see Goldston, 2003). Alternatively, clinicians may use a similar line of questioning to that presented above to assess current thoughts of suicide, such as the following:

“In the last week, how often have you thought about wanting to die or killing yourself? When was the last time your thought about killing yourself?”

Given their chronic risk status, youths with prior histories of suicide attempts or NSSIs are at moderate acute risk even if they do not experience current suicide ideation. Moderate acute risk indicates a risk level higher than what is found in the general population of youths who experience emotional distress, common psychopathologies such as mood and anxiety disorders, and recent negative life events. A moderate acute risk designation reflects the need for clinicians to remain vigilant and attuned to any possible signs that a suicidal crisis could develop and take appropriate preventative action steps in the event a crisis does develop (we provide details on action steps under Risk Management). Youths with prior histories of suicide attempts or NSSIs who currently experience suicidal thoughts are at high acute risk. High acute risk indicates the current presence of a suicidal crisis that could rapidly escalate to a suicide attempt. Youths at high acute risk need continuous monitoring; immediate steps should be taken to make the environment safe (see Risk Management). If youths at high acute risk do not agree to use a safety plan or caregivers and/or other trusted adults cannot provide continuous monitoring and make the home environment safe, clinicians should consider hospitalization until the acute risk level has decreased.

Current plans or intent for suicide.

The third decision point in the algorithm is the presence versus absence of current plans or intent for suicide. Again, some self- and interviewer-administered rating scales assess current plans and intent for suicide, including the C-SSRS (see Goldston, 2003). Example questions to assess current plans and intent for suicide include the following:

“When you think about killing yourself, what kinds of thoughts do you have? What plans have you made for killing yourself? Have you thought about how you might do it? What are the chances that you would act on thoughts of killing yourself?”

Youths who have a prior history of suicide attempt or NSSI and experience current suicidal thoughts that include a plan or intent for an attempt are at severe acute risk. Severe acute risk indicates that a suicide attempt in the near future is likely unless restrictive actions are taken. Although data are lacking to support the effectiveness of hospitalization in reducing risk of suicide, it remains the primary option to limit access to potentially lethal means and provide 24-hour monitoring. As such, we recommend hospitalization for youth at severe acute risk until the acute risk level has decreased.

Low Chronic Risk: No History of Suicide Attempt or Nonsuicidal Self-Harm

We present the algorithm for youths who do not have a prior history of suicide attempt or NSSI below the diagonal in Figure 1. Although these youths are not at elevated chronic risk of suicide, suicidal crises can arise and risk of suicide can escalate up to severe in some situations.

Current thoughts of suicide.

Having established that the youth has no prior history of suicide attempt or NSSI, the clinician proceeds to the second decision point in the algorithm: presence versus absence of current thoughts of suicide. In these youths, the absence of current thoughts of suicide leads to a designation of low acute risk. It is important to keep in mind that low risk is not equivalent to “no risk.” A low-risk designation still requires steps be taken to ensure the youth's safety (see below for action steps). The presence of current thoughts of suicide leads to a designation of moderate acute risk.

Current plans, preparations, or intent for suicide.

The third decision point in the algorithm is the presence versus absence of current plans or intent for suicide. The presence of current plans or intent for suicide or suicide attempt leads to a designation of high acute risk. Further, youths who have current plans or intent and have begun to prepare for an attempt or have access to the means to make an attempt are at severe acute risk. Example questions to assess current preparations for suicide include the following:

“What steps have you taken to prepare? For example, have you obtained the materials to do it, like collecting pills? Do you have access to firearms or (other means the youth endorsed thinking about using)? Have you thought about when and where you would do it?”

In addition to asking youths, it also is necessary to ask caregivers about access to potential means of self-harm in the youth’s environment, a point we return to when we describe safety planning.

Other Variables Influencing Risk Designation

The algorithm we present provides a guide based on empirical and clinical literatures. Although we encourage clinicians to be systematic in their approach to risk assessment and designation, we caution against inflexible adherence to the algorithm. In the presence of multiple other risk factors, such as recent negative life events (e.g., family conflict, romantic relationship problems, and legal/disciplinary problems), substance use problems, sleep disturbances (especially insomnia), aggressive behaviors, family history of suicide, or history of sexual abuse, a higher risk designation may be appropriate (Brent et al., 1999; Bridge et al., 2006; Fitzgerald, Messias, & Buysse, 2011; Goldstein, Bridge, & Brent, 2008; Hartley, Pettit, & Castellanos, 2018; Hill, Castellanos, & Pettit, 2011; Hill, Pettit, Green, Morgan, & Schatte, 2012; Pettit, Green, Grover, Schatte, & Morgan, 2011). When in doubt, clinicians would be wise to err on the side of caution and seek consultation from experienced colleagues.

Impulsivity is another variable that merits comment. Trait impulsivity is a risk factor for suicidal behaviors, but is not consistently associated with the impulsivity of a suicide attempt (Anestis, Soberay, Gutierrez, Hernandez, & Joiner, 2014) and may not distinguish people who think about suicide from people who attempt suicide (Klonsky & May, 2010; May & Klonsky, 2016). As such, trait impulsivity has limited utility in determining acute risk of suicide. There is ongoing empirical study into the percentage of attempts that are impulsive, as well as debate on how to define an “impulsive” suicide attempt. Definitional issues aside, suicidal crises can escalate rapidly in youths and attempts can occur with minimal planning (e.g., Simon et al., 2001). The field’s ability to assess and predict the likelihood of such rapid escalation is poor, a fact that highlights the importance of taking appropriate planning and prevention steps with youths at all levels of risk.

Risk Management: Safety Planning

After assessing risk and making a suicide risk designation, it is important to develop a corresponding intervention and management plan to decrease risk. Safety planning is a useful approach that clinicians can embed within larger treatment plans. We distinguish safety plans from “no-suicide contracts” or “safety contracts,” which simply request that clients agree not to kill themselves. Such approaches are insufficient and ineffective for managing suicide risk (Rudd, Mandrusiak, & Joiner, 2006). By contrast, safety planning provides clients with strategies for how to prevent and manage suicidal crises (Stanley & Brown, 2012). While there are various approaches to safety or crisis response planning (e.g., Jobes, 2006; Rudd, Joiner, & Rajab, 2001), we focus specifically on the Safety Planning Intervention (SPI), developed by Stanley and Brown (2008, 2012), because this approach is easy to implement and was designed for use as both a standalone intervention in acute care settings and as an intervention and management strategy in outpatient treatment. Research on the efficacy of the SPI is ongoing, and preliminary findings are promising. In a study comparing suicidal patients at emergency departments where the SPI was used to suicidal patients at emergency departments where the SPI was not used, data indicate that patients who received the SPI experienced fewer suicidal behaviors over a 6-month follow-up period (Stanley, Brown, Brenner, & Holloway, 2017; Stanley et al., 2015). The SPI has also been used as a component of treatments for suicidal behaviors in youth (e.g., Brent et al., 2009; Stanley et al., 2009). Further research is needed to establish its efficacy as a standalone intervention in youth.

Development and Rationale of SPI

Safety planning was originally developed as a strategy to be used in Cognitive Therapy for Suicide Prevention with adults (Brown et al., 2005). It was then expanded and adapted by Stanley and Brown to be used as a standalone intervention with adults (Stanley & Brown, 2008, 2012) and as a strategy within CBT for Suicide Prevention for suicidal adolescents (Stanley et al., 2009). The rationale for the SPI is that suicidal crises are usually time-limited, and consist of a period of suicidal desire and urges, followed by a decrease in the desire for suicide. Preventing individuals from acting on intense suicidal desire and urges allows time for the suicidal crisis to dissipate and pass. The SPI consists of six steps designed to help individuals recognize signs of an impending suicidal crisis and utilize internal and external coping strategies and resources in response to the crisis in order to prevent a suicide attempt.

General Considerations for Youth

Before conducting the SPI, it is important to consider the optimal level of involvement of caregivers in developing and implementing the safety plan. With children, it is often advantageous to conduct the entire SPI with children and caregivers together, as children may need more support or assistance in developing and utilizing the plan. With adolescents, clinicians need to use judgment when determining whether to involve caregivers in Steps 1–5 of the SPI. For some adolescents, it can be useful for maintaining rapport and fostering independent mastery of skills to develop Steps 1–5 with the adolescent alone, and then bring caregivers in to review the rationale for the safety plan, discuss how caregivers can support the adolescent in using the safety plan, and complete Step 6. For other adolescents, especially those who have limited insight into their thoughts and emotions, it can be helpful to involve caregivers in the development of all six steps.

A collaborative approach is essential for conducting the SPI, and this is especially critical when working with youths who are difficult to engage or ambivalent about treatment. To foster collaboration, it is important to encourage and support youths in coming up with items for each section of the safety plan; clinicians may assist in brainstorming and make suggestions. We find it helpful to encourage youths to write out safety plans using their own words while discussing each step. Clinicians may write out plans in youths’ words if preferred, although it is important to ensure that youths agree with each item before writing it on the plan.

Introducing the SPI

Before beginning the SPI, it is important for youths (and their caregivers, if applicable) to understand the rationale for a safety plan and how it is a useful tool for managing suicide risk. Poor understanding of the purpose and utility of the safety plan may decrease the likelihood that clients will use the safety plan when needed. One approach to establish the rationale for the SPI is to conduct a narrative interview of a recent suicidal crisis, one that has occurred within the past several weeks. In a narrative interview, clinicians obtain information about what happened before, during, and after the recent crisis (Brown et al., 2005; Stanley & Brown, 2012). Relevant crises to inquire about may be a recent suicide attempt or, in the absence of recent suicidal behavior, a recent period when suicidal ideation increased or was at its worst. Information obtained in the narrative interview provides insight into how suicidal crises develop and progress for youths, which provides a foundation for identifying personal warning signs. The narrative interview also provides a salient, personal example of how a suicidal crisis passed, setting the stage for clinicians to introduce the rationale for the SPI in a way that is personally relevant to youth. Conducting a narrative review of a recent crisis that passed can be especially helpful with youths who are currently suicidal by illustrating the transient nature of suicidal thoughts and urges.

Steps of the SPI

In Step 1, youths generate a list of personal warning signs (e.g., thoughts, behaviors, situations, emotional states) that typically immediately precede a suicidal crisis, with as much specificity as possible. These warning signs serve as a cue that it is time to use the safety plan. During this step, clinicians assist youths in recognizing signs that indicate an approaching crisis or period of suicide ideation. It can be helpful for clinicians to make mental notes of any potential warning signs that come up during the risk assessment and narrative interview. If youths have difficulty generating warning signs, clinicians may remind youths of potential warning signs discussed during the narrative interview and ask if these signs should be included in the plan.

As compared with adults, youths may focus more on general emotional states (e.g., sadness, anger) or external triggers, such as situations, particularly those of an interpersonal nature (e.g., conflict with significant other or friend). It is important to determine if emotional states or situations always leads to suicidal thoughts. If a general or vague warning sign does not always lead to a suicidal crisis, clinicians should query to elicit more information about the warning sign, with the goal of contrasting the times when it does lead to thoughts of suicide versus times when it does not in order to generate a more specific warning sign.

In Step 2, youths generate a list of “internal coping strategies” that they can employ by themselves to distract from the suicidal crisis or suicidal thoughts. Examples of strategies that may be useful for youths include watching a specific TV show or movie, listening to specific music, doing homework, or practicing a sport, instrument, or other hobby. It is important to ensure that the strategies are distracting in a positive way. For example, watching a sad show or video online is not likely to be a helpful distraction tool during a suicidal crisis. Youths may view strategies that involve technology (e.g., cell phone games or other distracting apps) as especially useful. The use of technology-based strategies also can allow youths to engage in distracting activities discreetly, if needed. During this step, it is important for clinicians to ensure that youths have a range of strategies that can be easily implemented during times when the options for distraction might be limited, such as while they are at school or in the middle of the night. In the context of safety planning, distraction is used specifically during crises to keep suicidal urges from escalating. It should not be viewed as a general emotion regulation strategy. Rather, distraction serves as an immediate crisis management strategy until more effective longterm emotion regulation strategies can be targeted and developed in treatment.

Sometimes youths have difficulty identifying internal coping strategies. When that happens, clinicians should first brainstorm with youths to generate ideas. If brainstorming yields no helpful ideas, clinicians can give examples of activities that have been helpful for other youths. Caregivers also can be helpful in generating ideas about activities that may be helpful distractors. When selecting activities to list on the safety plan, however, it is essential to make sure activities are personally relevant and feasible for youths to implement.

In Step 3, youths generate a list of people or social settings that can serve as distractors from the suicidal crisis or suicidal thoughts. In our experience, youths are more likely to identify peers than adults in this step, although some may list adults who could serve as good distractors. It is important to list people with whom youths have a positive, stable relationship and not people who may not be reliably good resources for distraction. With regard to social settings, examples that may be particularly relevant to youths include malls and local parks or recreation centers where others may gather to play sports. In some instances, youths may identify social media sites or online chat rooms and fora as social distractors. In these instances, clinicians should ensure that the activity involves interactions with others, versus merely viewing social media. Given that social media may be a conduit for bullying or other negative interactions that would not be helpful for youths in a suicidal state, it is also important to consider carefully the parameters around social media use as a distractor. Clinicians may discuss youths’ experiences with specific social media platforms or websites and explore how helpful a distractor they are likely to be.

In Step 4, youths generate a list of people to ask for help during a suicidal crisis. People listed in this step should include only trusted adults with whom youths perceive positive and supportive relationships. Most often, adults listed in this step will be parents or other caregivers. However, in some instances, a relationship with a caregiver is sufficiently strained and conflictual to make listing that caregiver counterproductive. In these instances, it is preferable to identify another adult who can help implement the safety plan and be a contact for assistance, such as an extended family member, a supportive teacher or coach, spiritual advisor, and so on. We recommend that clinicians discuss sharing the safety plan with any listed adults who are not primary caregivers, if youths are comfortable doing so. We do not recommend listing youths' peers in this step because peers are unlikely to have the knowledge and skills to provide help and they may not enlist the help of a responsible adult during a suicidal crisis (Kalafat & Elias, 1992).

In Step 5, youths generate a list of professional resources they can contact for help. The emergency numbers for all treating clinicians whom youths are willing to contact in a suicidal crisis should be listed in this step, in addition to other emergency resources, such as the nearest emergency department and the National Suicide Prevention Lifeline at 1-800-273-8255. As compared with adults, youths may be more interested in and comfortable with text- or chat-based crisis intervention services such as http://www.crisistextline.org or the Lifeline’s http://www.crisischat.org. Additionally, the Trevor Project (1-866-488-7386 or http://www.thetrevorproject.org) offers phone, text and chat-based crisis intervention for LGBTQ youth who are suicidal.

For adolescents with whom Steps 1 through 5 are completed without involving caregivers, clinicians should discuss how caregivers or other supportive adults could best support the adolescents in using the safety plan. After determining how others can best support adolescents in using the safety plan, clinicians should coach adolescents using role-plays or planning discussions on how to share this information and describe the safety plan when caregivers join the session for Step 6.

In Step 6, which involves planning to make the environment safe and limit access to lethal means, clinicians should always work collaboratively with youths and their caregivers or an adult who can assist in making the environment safe (Stanley et al., 2009). At this step, clinicians provide psychoeducation and rationale for limiting access to means for suicide. Clinicians should always ask caregivers whether youths have access to any means that were endorsed by youths, and should confirm with caregivers that youths do not have access to other, nonendorsed means of suicide including firearms, poisonous substances, and medications. It is essential to query both youths and caregivers about access to firearms (both within and outside the home). We recommend clinicians ask caregivers about access to firearms when they are speaking to them alone during risk assessment, rather than waiting to gather this information at the end of the safety planning process. If youths have access to firearms either inside or outside the home, clinicians should obtain information about how firearms are stored and collaborate with caregivers to develop a plan to temporarily remove firearms or implement safe firearm storage. This includes developing a plan for limiting access to any firearms outside of the home (e.g., at a friend’s house). In addition to firearms, it is also important for clinicians to help youths and caregivers develop a plan for limiting access to other means for suicide, such as medications, poisonous household substances, knives, razors, or belts. Clinicians should coach caregivers to implement agreed-upon means safety measures, such as using a pillbox for medication and keeping full bottles of medications locked away. With regard to household items that may be used for suicide (e.g., knives, razors, belts), clinicians should help youths and caregivers develop a plan to safely store these items temporarily (e.g., sharp kitchen knives locked in a cabinet) and coach caregivers in monitoring strategies, especially when the acute risk designation is moderate or higher. The latter include an open door policy (i.e., youth’s bedroom door is always open to enable visual monitoring) and periodic check-ins by caregivers. If caregivers or other adults cannot provide monitoring and make the environment safe, then alternatives including hospitalization should be considered for youths at moderate or higher acute risk. Finally, clinicians should make a plan to follow up with caregivers at a specified time to confirm the agreed upon means safety measures were implemented.

Using the Safety Plan

After completion of the safety plan, clinicians should query youth as to the likelihood that they will use each of the strategies listed and problem solve barriers to using the safety plan. Clinicians should then describe how to use the safety plan to respond to a suicidal crisis. When youth notice a personal warning sign, they should consult and select items on their plan to manage the crisis. Youths may choose to progress through Steps 2–5 in a sequential fashion, going to the next step up if the one before did not sufficiently alleviate the crisis. However, clinicians should also explain to youths that they can skip steps of the safety plan if necessary, such as when suicidal behavior is imminent and adult or emergency supports are needed to ensure safety (Stanley & Brown, 2012).

Clinicians should make copies of the safety plan and give them to youths and caregivers, and discuss where to keep copies of the safety plan and if alternate formats would increase the ease of use. Because it is important for youths to have the safety plan with them any time they experience warning signs for a suicidal crisis, they may prefer to adapt a paper safety plan to a smaller index card size or to enter their safety plan into Safety Plan smartphone apps. We have found the latter to be popular especially with adolescents.

We have had the experience of developing safety plans with youths in session, but then learning that they failed to use safety plans when they experienced a suicidal crisis. We recommend several strategies to reduce the likelihood of this occurring. When the safety plan is developed, clinicians can create a collaborative homework assignment with youths that will facilitate practice using the safety plan. For example, in the weeks following the creation of the safety plan, youths can add a daily review of the plan to their routine, even if they are not actively having suicidal thoughts. Daily review allows youths to familiarize themselves with the plan and increases the likelihood that they will remember to use the plan when a crisis occurs.

It also can be helpful to practice certain steps listed on the safety plan in session via roleplay, such as how to initiate social contact for distraction in Step 3 or how to seek support from adults in Step 4 (cf. Asarnow, Berk, Hughes, & Anderson, 2015). If time allows, or in subsequent sessions, we recommend practice using the safety plan while youths are in “hot” (i.e., emotionally charged) situations. This can be done by discussing an emotionally distressing topic (e.g., a recent negative life event) to elicit a moderate degree of distress, and then having youth practice working through steps of the safety plan. Practicing the safety plan in session while a youth is in a moderate state of distress may increase the likelihood that the plan is implemented outside of session. Of course, clinicians must take appropriate steps to address and reduce distress before the session ends.

It is important to view the safety plan as a living document. We recommended that clinicians check in about use of the safety plan when youths report experiencing warning signs since the last treatment session, and then problem solve barriers to its use. Clinicians should work with youths to update and modify the safety plan as appropriate over the course of treatment. For example, youths may use a strategy on the safety plan only to find out that it was not as helpful as they originally expected. In such instances, the strategy should be removed from the plan, and ideally, replaced with an alternative strategy. Additionally, as youths learn new coping skills in treatment, they can add these skills to the safety plan. Updating the safety plan is also a useful strategy to incorporate work done toward the end of the treatment with regard to relapse prevention and preparing to taper or discontinue sessions.

We recommend ending safety planning sessions with interventions to boost youths’ mood, such as a developing a list of reasons for living, listing youths’ positive qualities or strengths, or discussing good things in life (cf. King et al., 2013; Linehan, Comtois, & Ward-Ciesielski, 2012).

Documentation

Following risk assessment and management, clinicians must document their actions. At minimum, we recommend documenting (a) the risk designation, (b) rationale for the risk designation including the nature and frequency of suicidal thoughts, (c) actions taken to manage risk, and (d) future steps. For example, we would note (a) client is at low acute risk of suicide; (b) because she reported having thoughts about suicide approximately two times per week but denied plans, intent, or preparations and denied a history of nonfatal attempt or NSSI; (c) a safety plan was developed with client and then reviewed with the caregiver; and (d) at the next session, risk will be re-assessed and the safety plan will be reviewed and modified as needed. We also recommend making a copy of the completed safety plan and keeping it in the client’s file. Of course, clinicians may opt to elaborate on each of these points and address other relevant points. For a more in-depth discussion of recommendations for documentation, such as providing reasons why certain actions were not taken, we refer readers elsewhere (e.g., Joiner, Walker, Rudd, & Jobes, 1999; Linehan et al., 2012).

Case Illustration

A 15-year-old girl, Anna, presented at our outpatient clinic with complaints of anxiety and depression. At an intake evaluation, we briefly met together with Anna and her mother, then met individually with Anna’s mother for several minutes while Anna sat in the waiting room, and then met individually with Anna while her mother sat in the waiting room. During the joint meeting, Anna and her mother reported that Anna felt highly anxious in social situations for as long as they could remember and felt depressed off and on for the last year, with the severity of depressive symptoms having escalated in the past month. Anna had been taking sertraline for anxiety and depression under the care of a psychiatrist for approximately 1 year. During the individual meeting, Anna’s mother reported that Anna had never attempted suicide or intentionally injured herself, and that to her knowledge Anna had not thought about hurting herself. She stated that there was no firearm in the home and Anna did not have access to firearms outside the home as far as she knew.

During the individual meeting with Anna, she reported ongoing arguments with her parents, usually prompted by her failure to get up for school on time or maintain a clean room, and a breakup with her first boyfriend about 2 months ago. When questioned about suicidal thoughts and behaviors, Anna denied a history of suicide attempt or NSSI. She indicated that she had thought about whether life was worth living off and on for the past year, and that she began having thoughts about killing herself in the past month. She had these thoughts a few times a week, usually following an argument with her parents. When questioned about a plan, Anna indicated that she had thought about taking the sertraline bottle from her mother’s purse and swallowing as many pills as possible, although she had not worked out details of when she would do it and had not prepared for an attempt. She also indicated that the thought of attempting suicide was “very scary” to her and she did not believe she would act on her thoughts. She had not disclosed her suicidal thoughts to anyone, including her parents or psychiatrist.

We designated Anna’s acute risk as moderate, based on the absence of a prior history of suicide attempt and NSSI and the presence of current suicide ideation and a plan, albeit not well formulated and with no suicide intent. Although her plan was not well formulated, she did have easy access to the means to attempt suicide when she was at home, as her mother’s purse with the sertraline pills was usually left in a common family area. Anna had experienced a romantic breakup within the past 2 months and regularly argued with her parents. However, she did not present with substance use problems, aggressive behaviors, family history of suicide, history of sexual abuse, or sleep disturbance. Thus, we kept her acute risk designation as moderate. When queried, Anna indicated that she did not have access to other means of suicide, including a firearm inside or outside the home.

Based on the information obtained in the interview and her risk designation, we then conducted a narrative interview of a recent suicidal crisis. Anna identified an evening in the past week when she had intense thoughts of suicide following an argument with her mother about cleaning her room. She stated that prior to the onset of suicidal thoughts that evening, she had been doing homework in her room when her mother came in to talk to her and noticed clothes on the floor of her room. Her mother commented on the clothes on the floor, and Anna responded that it was her room and she could do whatever she wanted in her room. An argument ensued and escalated to yelling. Her mother eventually ended the argument by leaving Anna’s room. Anna reported that when she was alone in her room, she felt guilty about yelling at her mother and started to think that she was worthless and it would be better for everyone if she were dead. She then started thinking that she could use the sertraline in her mother’s purse to kill herself, which she stated was a very scary thought. Anna stated that she wished she had someone she could talk with to help her feel better, but she could not think of anyone to call, which made her feel lonely. She stated that she tried to continue working on homework, but still thought about killing herself. She reported that she eventually turned on music, went to sleep, and woke up feeling somewhat better the following morning (i.e., she was no longer thinking about killing herself).

Following the narrative interview, we introduced safety planning and discussed the rationale for the SPI using examples from the narrative interview. We explained how the safety plan could be helpful to Anna in such moments and suggested that we work together with her and her mother to develop a safety plan that she could use to help keep herself safe when she experienced suicidal thoughts. Anna expressed concern about disclosure of personal information to her mother, especially details regarding her romantic breakup and specific thoughts about her family members following arguments with them. We came to an agreement with her that sharing those specific details with her mother was not necessary to ensure her safety or develop the safety plan, and therefore we would not disclose them. Instead, we would disclose her thoughts of killing herself and discuss her personal warning signs for an impending suicidal crisis. We further agreed that we (the clinician) would initiate the discussion with her mother and then all of us would work together as a team to develop the safety plan.

We brought Anna’s mother back into the treatment room and explained that we had a good, productive meeting, and that an issue had arisen that we needed to address as a team. We then disclosed that Anna had been having thoughts of taking a large quantity of sertraline pills to end her life, and explained that such thoughts are common among adolescents who are feeling very distressed. We proceeded to present the rationale for safety planning to Anna’s mother, emphasizing that the plan would assist Anna in coping with suicidal thoughts, and that we were optimistic that treatment would be helpful in reducing Anna’s distress and decreasing the frequency and intensity of her suicidal thoughts. We then proceeded to develop a safety plan with Anna and her mother (see Figure 2).

FIGURE 2.

FIGURE 2

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Case Illustration Safety Plan

Copyright © Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. Reprinted with permission, http://www.suicidesafetyplan.com.

In Step 1, Anna identified thoughts of being worthless following arguments with family, thoughts that finding another romantic partner was hopeless, and feelings of loneliness as personal warning signs of a potential suicidal crisis that would cue her to use the safety plan. In Step 2, Anna identified several activities that could distract her, including listening to music by the band Coldplay and playing Pokemon Go on her cell phone. Her mother also suggested drawing as a possible distraction because Anna had enjoyed art for several years. Anna agreed and we added drawing to the plan in Step 2. In Step 3, Anna identified one friend at school, a small group of online friends, and her older sister who no longer lived at home, all of whom she could converse with to distract from suicidal thoughts. Anna was not able to identify any social settings that could be distracting, but we made a mental note to revisit this topic in subsequent treatment sessions. Before proceeding to Step 4, we problem-solved to ensure at least one of the social contacts listed in Step 3 would be available at almost all times, although we agreed it might not be feasible to seek out social contact for distraction if she woke up in the middle of the night and began to have thoughts of killing herself. We decided that if that she found herself in that situation, she would jump directly from Step 2 to Step 4. Also before proceeding to Step 4, and in light of Anna’s social anxiety, we checked with her to make sure she would feel comfortable initiating social contact with each person listed in Step 3. In Step 4, Anna identified her parents, or if they were not available, her grandmother, as people she could go to for help during a crisis. In Step 5, Anna and her mother identified our clinic and Anna’s psychiatrist as professional resources that she would be comfortable reaching out to for help in the event of a suicidal crisis, followed by a suicide hotline, and then the nearest hospital emergency department if the crisis continued to escalate.

In Step 6, we confirmed with Anna’s mother that she currently kept Anna’s sertraline pills in her purse. Her mother offered to lock the pills in a chest in her room and keep the key in a location unknown to Anna. She would continue to give Anna one sertraline pill daily. Anna agreed to this plan. Her mother again confirmed there was no firearm in the home, Anna did not have access to firearms outside the home, and Anna did not have any sharp objects in her room.

Anna decided that the best place to keep a copy of the safety plan was in her purse. She further decided to share it with her father and grandmother so they would be aware of the plan in case Anna reached out to them for help. Anna and her mother also agreed to inform her psychiatrist of Anna’s suicidal thoughts and safety plan at their next scheduled appointment. We reviewed the completed safety plan with Anna and her mother, asking Anna to describe the specific steps she would take and the circumstances that would cue her to use the safety plan. We also collaboratively developed a homework practice that Anna would briefly review the safety plan every night during her bedtime routine and use it if she experienced any personal warning signs at other times. Finally, we collaboratively developed a list of Anna’s reasons for living. Anna identified love for her family, dog, and friends, and her desire to become a doctor and start a family of her own in the future as reasons for living. Because Anna emphasized family in her reasons for living, we then spent several minutes talking about her favorite things to do with family, including some of her favorite memories of being together with her family. The purpose of this last step was to induce a positive mood prior to ending the session.

Conclusion

In this article, we presented specific, pragmatic steps that mental health clinicians can implement to assess and manage suicide risk in youth. We encourage clinicians to consider the optimal ways to adapt and implement these steps in the settings where they work and the populations with whom they work. There is no perfect, one-size-fits-all approach to suicide risk assessment and management. However, clinicians can arrive at an appropriate risk designation by regularly and systematically assessing prior history of self-harm behaviors and the nature of current suicidal thoughts, and can manage youth suicide risk in a variety of settings by using safety planning. As noted by others (Goldston & Compton, 2007), safety planning not only provides a pragmatic approach to intervene and manage risk, but can also provide a useful complement to risk assessment; if youths are not willing or able to engage in developing and using a safety plan, it indicates more restrictive actions are needed to keep them safe.

Highlights.

  • Chronic risk is determined by prior history of suicide attempt or self-harm

  • Acute risk is determined by current suicide ideation, plans, intent, and preparations

  • Documentation of risk designation, actions taken, and future steps is essential

  • Safety planning is an easy to implement approach for managing suicide risk

Acknowledgments

We gratefully acknowledge Dr. Gregory K. Brown for his contributions. Support for writing this piece comes from NIH R34MH097931 and NIH UH2MH101470. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

The authors declare that there are no conflicts of interest.

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Contributor Information

Jeremy W. Pettit, Florida International University

Victor Buitron, Florida International University.

Kelly L. Green, Perelman School of Medicine of the University of Pennsylvania

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