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Key points
- Keeping a child safe is the first priority. It's never wrong to send a child to the emergency room if they say something that sparks concern.
- Screening questions can help determine a patient's level of risk of suicide.
- A patient may be able to go home rather than the ER if both they and their caregivers agree on a safety plan.
“The first thing I would say to any clinician is that it’s never wrong to send a child to the emergency room,” said Amy Dryer, MD, pediatrician and REACH Institute faculty member.
Having spent 10 years in a hospital emergency department, Dryer is intimately familiar with the criteria ER physicians use to decide to admit psychiatric patients: a medical condition, suicidal ideation with a lethal plan, homicidal ideation, or active psychosis.
However, she emphasized that your decision to refer to the ER doesn’t hinge on whether the patient is likely to be admitted. “If what they’re telling you makes you uncomfortable,” she said, “go ahead and refer them.”
Assess risk factors
Suicidal ideation is high among teenagers. According to the Centers for Disease Control and Prevention, 18.8 percent of teenagers reported having considered suicide in 2019, though only 2.5 percent required medical intervention after a suicide attempt.
Dryer outlined factors that make young patients more likely to complete suicide:
- Presence of depression, severe anxiety, or impulsivity; severe substance abuse
- Having a specific plan
- Family history of suicide or previous attempts
Dryer and The REACH Institute recommend the ASQ (Ask Suicide Screening Questions) five-question screening tool to help you assess whether a patient is in imminent danger.
“Suicidality exists on a spectrum, from passive ideation through having a plan to complete suicide,” said Dryer. “The trick is figuring out where this patient is on that spectrum—keeping in mind that, for one kid, that spectrum might be two football fields wide, while for another it’s only 10 yards.”
Dryer also pointed out that self-harm behaviors like cutting, which have been treated as risk indicators, do not necessarily correspond to a high risk of suicide. There are three reasons for cutting, she said: as a relief valve, as a distraction, or as practice for suicide. “That last is the one I worry about. The first two are coping mechanisms—not healthy ones, but also not pre-suicide behaviors.”
Assess safety factors
Here are the conditions Dryer wants to have in place in order to send a child home rather than to the ER:
- The caregivers are on board. They understand the severity of the problem. They want to do whatever they can to keep the child safe and alleviate the child’s suffering.
- The patient is on board. They accept that they have a problem and are willing to co-construct and abide by a safety plan.
To construct a safety plan with your patients, consider the Stanley-Brown safety plan template. A resource for patients is the My3 app, which offers suicide prevention support.
Know the options
Knowing how the ER will handle your patient and what other options are available in your community can help you better care for patients whose suicidal ideation concerns you.
If you haven’t already, investigate the ER(s) in your community, whether by asking colleagues or calling the attending physician. How long is the wait? What is the availability of beds for pediatric psychiatric patients—and are those beds on-site or elsewhere?
“Hospital emergency rooms often don’t feel like safe places for LGBTQIA+ youth,” said Dryer. “Or the wait could be days. You would still send the patient if it’s the only way to keep them safe, but you wouldn’t submit them to that trauma if there are other options.”
In many communities, crisis intervention units provide another option. They often provide wraparound services, such as family support, that neither you nor the hospital can readily provide. To find out what’s available locally, start with your state health department’s website.
Make the referral
“I always do a warm hand-off [when referring to the ER]," said Dryer. “I want to talk to the attending or admitting physician to tell them who this is and why I’m sending them.”
Furthermore, said Dryer, “I am 110 percent transparent with both the patient and the family. I tell them why I’m concerned and why it’s important for the patient to go straight to the ER. If the patient and caregiver agree, great! But if the caregiver insists that the child will be okay at home," Dryer says, “I’m prepared to call 911 if need be.”
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.
