Toolkit: Children's Hospitals

Zero Suicide in Children's Hospitals

The Zero Suicide Toolkit for Children's Hospitals is an adaptation of the Zero Suicide Toolkit that provides implementation strategies and resources tailored to the needs of health and behavioral healthcare systems that serve children and youth populations. Since 2020, the Zero Suicide Institute at EDC has worked with almost 40 children’s hospitals on implementation in partnership with Cardinal Health Foundation and Children’s Hospital Association. This adaptation has been informed by what we have learned and will continue to incorporate experiences and resources from our collaboration. 

Resources can be found in the toolkit adaptation below and on the Children and Youth resource page. 

We recommend that Zero Suicide implementers read the Zero Suicide Toolkit before or alongside each section of this toolkit adaptation. 

Suicide in Youth Populations

Zero Suicide is a highly effective framework for the implementation of suicide safer care. Yet applying the practices of Zero Suicide in pediatric populations comes with unique challenges. Variability in cognitive development, learning, language, and emotion regulation must be considered, as well as the impact of adverse child experiences, historical and intergenerational trauma, and the social and political climate that affects a young person's sense of safety and wellbeing. 

When working with children and youth, systems must also engage parents, caregivers, and other adult supports identified by the youth. It is important to be aware of connections youth may have to systems outside of health and behavioral healthcare that play a vital role in supporting suicide safety, such as schools, child welfare, and juvenile justice.

Childhood Mental Health Concerns

The rates of childhood mental health concerns and suicide have risen steadily in recent decades with COVID-19 exacerbating the crisis. Stressors such as social isolation, academic and extracurricular disengagement, grief, family disruption, and economic instability underpin increased visits to emergency departments, suicide attempts, and suicide deaths. While suicide impacts all populations, youth of differing cultures, communities, and identities are disproportionately impacted:

• Suicide rates are higher among older youth and males
• American Indian/Alaska Native youth have the highest rates of suicide
• Suicide rates of Black youth are rising and rates for Black youth under 13 are twice that of White youth of the same age
• LGBTQIA+ youth are at a greater risk
• Youth involved in juvenile justice and foster care system are at increased risk

Youth with health and developmental needs, youth who are unhoused, and youth living in rural communities or low-resourced urban settings disproportionately experience risk factors for suicide, including substance use and psychiatric disorders, exposure to ACES and developmental trauma, and increased access to lethal means1. More than ever, there is a need to address health equity in youth suicide prevention and intervention.

Cultural Implications and a Multi-Systems Approach

Connecting youth to care and bridging transitions between systems and community supports and services is essential for safer suicide care. Children and youth, particularly those at the greatest risk, are often engaged with multiple systems, including schools, child welfare, juvenile justice, and healthcare. Their day-to-day lives include engagement with community services and supports, such as recreational activities, libraries, faith-based services, and other programs. Children and youth are largely dependent on the adults in their lives (i.e. parents, caregivers, teachers, coaches) for emotional and practical supports that promote wellbeing and safety. The need for more communication, collaboration, and coordinated care is paramount, particularly in places where access to psychiatric care is limited.  

Research into youth suicide prevention is still young, but several tools to support effective screening and assessment and developmentally appropriate interventions are emerging. Much work still needs to be done to apply these resources to diverse populations. Providers of care that do not account for unconscious bias, internalized stigma, institutional racism, the experience of trauma, or negative past experiences with healthcare, may not garner valid and reliable information. For example, discrimination in the broader social and political climate, such as anti-LBGTQ+ laws, may also contribute to youth suicide risk. 

At the same time, for many young people, a strong sense of cultural identity and connection to community serve as protective factors for our nation’s youth. Cultural factors play a significant role in suicidal behavior and, while there is much to learn about the intersection of sociopolitical factors and suicide, we must acknowledge that our youth don’t develop in a vacuum.

Family Engagement

Family-level factors, such as relationship quality, history of suicidal behavior, mood disorders in family of origin, and other contextual factors have an important role in the development of suicidal thoughts and behaviors in youth. Research demonstrates associations between suicide and levels of family conflict, low parental monitoring, abuse, and separation from parents. 

Characteristics of the family environment, such as firearm ownership, also impact risk. Therefore, family engagement is key to effective suicide prevention and intervention. This is evident when creating safety in the home, as in the safe storage of firearms. Firearms that are locked, unloaded, and stored separately from ammunition mitigate risk. 

Many youth spend more time in school settings than they do at home or with other caregivers, so supporting families to communicate with multiple systems and individuals to support safety becomes a critical component of Zero Suicide implementation. Just as family factors may contribute to suicide risk, they can also moderate risk and serve as powerful protective factors for youth. 

Parenting style, such as establishing clear expectations for behavior, creating structure, and monitoring also supports safety for youth. Families, caregivers, and support systems also have a critical role in fostering individual protective factors in youth. Problem-solving skills, emotion regulation, and coping skills can be taught, modeled, and promoted by strong family and caregiving systems. Given the vital role of the family system, incorporating family and caregivers in efforts to prevent youth suicide is paramount. Interventions that engage the larger family system and promote the health, wellness, and functioning of the caregivers must be considered as systems define safer suicide care.

• 1

  Ackerman, J.P. & Horowitz, L.M. Youth Suicide Prevention and Intervention: Best Practices and Policy Implications. SpringerBriefs in Psychology: Advances in Child and Family Policy and Practice, 2022.  Available at https://link.springer.com/book/10.1007/978-3-031-06127-1.

LEAD Defined

Lead a system-wide culture change committed to reducing suicide deaths.

Organizational leadership is a key component of the Zero Suicide framework. It includes the explicit communication of a commitment to the resources, training, policy development, and transformative change required to achieve the goal of zero suicides. In addition to building organizational capacity to implement the framework, leadership at all levels helps to create a culture that supports the belief that zero deaths by suicide is an attainable goal, and responds to adverse events through the lens of a just culture—one that does not blame individuals but seeks to understand systemic influences and how practices, policies and protocols can be improved. 

Organizational Self-Study

Completing the Organizational Self-Study is a common early step in Zero Suicide implementation. Pediatric primary care, youth and family behavioral health organizations, schools, and other youth-serving community-based providers are encouraged to complete a version of the Organizational Self-Study most appropriate for their setting. Responses may differ when assessing policies and practices related to adult services versus children’s services. It may be most helpful to assess programs separately. Consider the following as you assess your organization’s strengths and opportunities:

• Suicide prevention services are directed toward individuals experiencing suicidal thoughts and behaviors. This is consistent with a collaborative, person-centered approach. However, most children and youth will benefit from the support of adult caregivers to use their safety plan, to ensure lethal means safety, and to access suicide care. Suicide care practices and protocols should intentionally engage parents and other adult caregivers, as well as relevant systems (i.e. schools, foster care) in such a way as to be safe and supportive of youth needs while complying with organizational and regulatory policies.
• Engaging individuals with lived experience is an important component of the Zero Suicide framework. While opportunities for youth may be limited in many settings, intentional effort should be made to allow for youth voices. In addition, parents and caregivers have an important perspective that can play a key role in the design, implementation, and improvement of suicide prevention and intervention policies and services.
• Anyone working with children and youth should have specific training to understand the development and the impact of trauma and adverse childhood experiences.

Lived Experience

The voices of lived experience is a key component of the Zero Suicide framework. Organizations are encouraged to include individuals with lived experience (attempt survivors and loss survivors) in decision-making roles, such as serving as a member of the Implementation Team, reviewing communications and policies, and employing certified peer support staff to deliver services as part of the suicide care pathway.

In the context of working with children and youth, parents and caregivers who have lived experience caring for a child with suicidality can and should be included in the aforementioned roles. As of 2019, two-thirds of states allowed for Medicaid billing of youth and family peer support services.1 The National Federation for Families offers a National Family Peer Specialist Certification in collaboration with affiliates in nearly every state.

In addition, there are numerous opportunities to include youth voices and promote a culture that respects youth experiences, recognizes their strengths, promotes safety, and supports collaborative care. Examples include:

• Inviting youth to contribute artwork and text to the design of caring contacts, suicide prevention awareness materials, and crisis support information (i.e. posters, social media)
• Asking youth for suggestions on how to create a physical environment that is safe, supportive, and welcoming (i.e. seating, lighting, music, availability of fidget toys or other wellness tools)
• Encouraging feedback about their experiences (i.e. surveys, focus groups, informal presentations to Implementation Team)

The following resources offer opportunities to engage and elevate youth voices:

• WISE’s Up to Me guides individuals to safely share their stories about mental health disorders and recovery
• Jed Foundation, Active Minds, and TrevorSpace offer programming to support youth voice through advocacy, awareness campaigns, tools to develop positive coping strategies and help-seeking behaviors, and strategies to support peers
• Youth Move National supports local chapters that engage youth in advocacy, hosts leadership academies, and provides consulting/TA to organizations to assess and build capacity for youth involvemen

REMINDER: Visit the Zero Suicide Toolkit for additional information and resources.

• 1

  Schober, M. & Baxter, K. (2020). Medicaid Funding for Family and Youth Peer Support Programs in the United States. National Technical Assistance Network for Children’s Behavioral Health.  Available at https://www.nasmhpd.org/sites/default/files/State%20Medicaid%20for%20Parent%20Peers%20Support%20July%202020.pdf. Accessed on September 21, 2023.

TRAIN Defined

Train a competent, confident and caring workforce.

In a Zero Suicide implementing organization, all employees, clinical and non-clinical, are assessed for their beliefs, knowledge, and skills needed to care for individuals at risk for suicide and receive training appropriate for their role, including basic suicide awareness for all staff. While youth-specific training for providers is a little more limited, Suicide Care Training Options offers a list of programs appropriate for both clinical and non-clinical staff. In addition, those working with children and youth would also benefit from an understanding of youth development, child and adolescent mental health, developmental and learning disabilities, and the impact of trauma and adverse childhood experiences.

It is imperative that we also train staff to understand organizational policies and protocols specifically related to their role in delivering safer suicide care. The Zero Suicide Workforce Survey is a highly accessible tool that assesses staff perception of their knowledge and comfort when interacting with and supporting individuals at risk for suicide and their families and caregivers.

Suicide Awareness for Communities, Schools, Parents and Caregivers

In addition to training staff, youth-serving organizations are encouraged to promote suicide awareness in the community, including in schools, to parents and caregivers, and to youth. Teachers, families, and peers are often the first to recognize when a young person is struggling with thoughts of suicide. They must have the knowledge and skills to offer support and encourage help-seeking from a professional. Many states recommend or require mental health and suicide prevention education for students and suicide awareness training for educators, including twenty-one states that have passed the Jason Flatt Act, requiring educators to receive annual training in youth suicide prevention. In practice, many schools extend this important learning to parents and the community.

The American Academy of Pediatrics offers resources to inform parents and caregivers about common risk factors and warning signs, strategies to engage youth and medical professionals in discussions about suicide, and other helpful topics. Many communities also have access to the trainings below:

• Youth Mental Health First Aid is an evidence-based training designed for parents, caregivers, family members, educators, community members, staff working in youth-serving organizations, and anyone else working with youth. Participants gain a basic understanding of emerging mental health challenges and crises (including suicide), and typical adolescent development, and learn to use a five-step action plan to support youth and refer them to professionals for further screening and assessment.
• Evidence-based, basic awareness trainings teach people to recognize the warning signs of suicide risk and connect individuals to professionals for screening and assessment. They include:
  • Suicide Alertness for Everyone:  Tell, Ask, Listen, Keep Safe (safeTALK)
  • Question, Persuade, Refer (QPR)

Suicide Awareness for Youth

• Signs of Suicide (SOS) is an evidence-based youth education program for grades 6-12 that teaches students to recognize the signs of depression and suicide in themselves and their friends, to recognize the role of social media, and to seek help and hear stories of hope and recovery. SOS also provides guidance to trusted adults (i.e. parents, teachers) on how to provide support and includes a universal screening component. Research has demonstrated:
  • 64% of 9th-grade students were less likely to report a suicide attempt
  • Middle school students demonstrated improved knowledge about suicide and suicide prevention
  • Middle school students with pre-test suicide ideation and planning reported fewer suicidal thoughts and planning behaviors in 3-month post-test
  • Unfortunately, there were no significant differences in help-seeking behaviors

REMINDER: Visit the Zero Suicide Toolkit for additional information and resources.

 ___________________________________________________________________

¹ Schilling, E.A., Aseltine Jr, R.H., and James, A. (2016). The SOS Suicide Prevention Program: Further Evidence of Efficacy and Effectiveness. Prevention Science, 17(2), 157-166.

² Schilling, E. A., Lawless, M., Buchanan, L. & Aseltine, R.H. (2014).  Signs of Suicide Shows Promise as a Middle School Suicide Prevention Program. Suicide and Life-Threatening Behavior, 44(6), 653-667.

IDENTIFY Defined

Identify individuals with suicide risk via comprehensive screening and assessment.

Universal screening is recommended as part of the Zero Suicide framework. Every individual entering the system is screened for suicide thoughts and behaviors, and at regular intervals. Following all positive screens, an assessment is conducted to determine the level of risk and develop a plan for appropriate interventions. Screening and assessment are important but distinct components of the Identify element.

Research indicates that children and youth with suicide ideation often do not have a known mental health concern and that screening for mental health alone does not reveal suicidality—we need to directly ask about suicide. Furthermore, one-third of all youth with suicidal ideation will make a plan, and up to 60% will make a suicide attempt¹. Therefore, suicide-specific screening is essential to early intervention. The American Academy of Pediatrics recommends universal screening for youth ages 12 and up and clinically indicated screening for children between 8 and 11 years of age. Under the age of 8, screening is not indicated but clinicians should assess for suicide thoughts and behaviors when warning signs become evident². It should be noted, however, that Black, indigenous, and people of color have been largely excluded in suicide research, so the following tools may not be culturally sound. When possible, efforts should be made to use culturally responsive language, translations, and clinical judgment.

Below are examples of evidence-based tools for suicide screening and suicide risk assessment. They can be used in many different organizations, including schools, youth-serving community-based organizations, and healthcare settings, such as the emergency department, inpatient, and outpatient medical care. 

Screening

• The National Institute of Mental Health developed Ask Suicide-Screening Questions (ASQ), a 4-item tool to quickly screen individuals. The ASQ toolkit provides guidance, such as scripts, implementation workflows, and training.
• The Patient Health Questionnaire-9 (PHQ-9A), often used in healthcare settings, measures depression severity and includes a single question that asks about the presence of suicide ideation. The PHQ-A includes has been modified for use with adolescents, and includes questions about past month suicide ideation and lifetime experience of suicide attempts.
• The Columbia Suicide Severity Rating Scale (C-SSRS) 6-question screener has a version with language appropriate for young children (ages 6-11) and another for children ages 4-5 or those with cognitive impairment. Both offer modifications to wording but efforts should also be made to obtain information from collateral contacts to support accuracy of the screener. There is also a version for schools that includes a response protocol appropriate for the setting, and the C-SSRS is available in multiple languages.
• A novel approach to screening is the Computerized Adaptive Screen for Suicidal Youth (CASSY). This technology-based tool, originally designed for universal use in emergency departments, may feel very comfortable for children and youth.  It can also be easily integrated into electronic health records.

Positive screens for suicide should be followed up immediately or as soon as possible with an evidence-based risk assessment.  The purpose of assessment is to determine next steps to plan for safety.

Brief Suicide Risk Assessment for Children and Youth

• The Columbia Suicide Severity Rating Scale (C-SSRS) can be paired with the SAFE-T protocol, a five-step model for identifying risk factors and protective factors, suicidal intensity, risk stratification and interventions, and documentation. A mobile app for clinicians includes treatment resources, case scenarios, and conversation starters.
• The Ask Suicide-Screening Questions (ASQ) is often followed by the Brief Suicide Safety Assessment (BSSA)—see ASQ toolkit for worksheet and guidance. It begins with validating and praising the individual for their response to the ASQ and prompts further disclosure about frequency, suicide plan, and past suicide behaviors, as well as an understanding of symptoms, social supports, and stressors. Finally, it includes a section for interviewing the youth and their parents or caregivers and safety planning. NOTE: additional resources for safety planning are found in the ENGAGE element.

Anticipated Barriers to Suicide Risk Screening and Assessment with Children and Youth

Common barriers to implementing suicide screening and risk assessment in settings that serve children and youth include staff lack of knowledge, discomfort with asking about suicide, concerns about lack of resources for follow-up, time constraints, and resistance from parents and caregivers¹. Training and guidance are available for the evidence-based tools shared above and a range of professionals can be trained to screen and assess for suicide risk. Start by training individuals most comfortable with the topic to model effective practice and demonstrate that it can be integrated into existing workflow. In some instances, partnerships with other community providers can be helpful to support risk assessment if organizations do not have their own internal capacity.

Educate staff and families that asking children and youth about suicide does not increase their level of distress or suicidal thinking, or cause them to make an attempt. Instead, it gives them permission to talk about feelings that are likely very scary and difficult to understand, and opens the door for intervention and support.

When possible, screen youth in private, not in the presence of a parent or adult caregiver. For many reasons, a child may be reluctant to disclose in their presence. They may be concerned about making their parents feel sad or fear they will not be believed. In some instances, they may have already disclosed to an adult who was not able to offer a helpful response. Some youth may be concerned that sharing their suicidal thoughts might elicit questions they don’t feel comfortable answering, such as disclosing a traumatic experience, or sexual identity or orientation. Providing education to parents and caregivers in advance about youth suicide and the support and treatment that is available will be very helpful. Strategies to effectively support follow-up and access to care are provided in the ENGAGE and TRANSITION.

REMINDER: Visit the Zero Suicide Toolkit has additional information and resources.

___________________________________________________________________

¹ Milliman, C.M., Dwyer, P.A., Vessey, J.A. (2021). Pediatric Suicide Screening: A review of the evidence. Journal of Pediatric Nursing, 59,1-9.

² American Academy of Pediatrics. Suicide: Blueprint for Youth Suicide Prevention. Available at https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/

ENGAGE Defined

Engage all individuals at risk for suicide using a suicide care management plan.

When organizations commit to Zero Suicide, anyone identified as being at-risk for suicide is engaged in a plan of care that is collaborative, closely monitored, carefully documented, and regularly reviewed. Special considerations need to be taken when working with children and youth.

Youth need a pathway to care that is specific to their unique needs and includes information and support for parents, caregivers and other caring adults.  A youth-focused suicide care plan should include:

• Screening and assessment tools appropriate for youth and the specific setting
• Modifications for very young children
• Clear policies to obtain and document consent, and engage appropriate supportive persons (parents, caregivers, school) in the child’s suicide care
• Youth-appropriate evidence-based interventions and treatment
• Youth-appropriate caring contacts
• Youth-appropriate language for communicating the child (when appropriate) and their caregiver(s)
• Identification of barriers to care (i.e. transportation, time, insurance/finances)
• Strategies to mitigate the above challenges since youth are often reliant on others

Two examples include:

• Seattle Children’s Hospital Zero Suicide Initiative Pathways
• Vermont Center for Children, Youth and Families’ Suicide Care Pathway: Family Map

Safety Planning with Children and Youth

Parents, caregivers, and adult supporters are an important part of safety planning. Anyone who is a part of the safety plan needs education about their role and how they can best support the youth. In addition, adults are integral in facilitating and monitoring for lethal means safety. Consistent with collaborative safety planning, the youth remain at the center of the decision-making process, so active consent from the youth to involve adults is crucial. The Suicide Prevention Resource Centers hosts a free, self-paced, online training called, Safety Planning for Youth Suicide Prevention. Below are the key components of a safety plan with considerations for working with children and youth:

• Identify Warning Signs: Youth may not possess the self-awareness to recognize their unique warning signs. They may need some education or be encouraged to seek input from parents or caregivers.
• Identify Internal Coping Strategies: Youth are sometimes dependent on others for financial resources, transportation, and other practical supports to practice coping strategies. Help youth identify strategies that are feasible given their unique circumstances, and problem-solve when appropriate. For instance, if playing a video game is a good internal coping strategy but they do not have access to video games or there are restrictions on their access, help them explore this with parents/caregivers.
• Identify People and Settings for Distraction: Educate youth about the different levels of support they may need and who is most appropriate to provide help in each situation. Peers should be listed as social support for distraction while adults should be listed as people to provide help in a crisis (see below).
• Identify People to Help in a Crisis: Review and practice with youth how to communicate with adult supporters when they need assistance. This could include text messaging or other non-verbal communication methods to express their needs.
• Identify Professional Help and Crisis Contacts: Ask the youth about their preferred means of contact. For example, they may choose the Crisis Text Line over the 988 Lifeline but don’t make that assumption – ask for their preference and then help them put it in their cell phone, if available. Consider safety planning apps but do not limit this to technology applications. Include a printed version of resources for when their battery dies or if they lose access to their phone for other reasons (i.e. breakage, punishment).

Safety plans for youth should be developmentally appropriate and in their own words and language. Consider using pictures, images, drawings, or emojis. For very young children, Gizmo’s Pawesome Guide to Mental Health is a great resource that includes education for parents and caregivers.

Lethal Means Safety for Families

Counseling youth, as well as their parents and caregivers, about lethal means safety is a critical part of safety planning. Lethal means interventions that include psychoeducation and strategies to reduce access can be lifesaving. In addition to Counseling for Access to Lethal Means, an award-winning, free, self-paced, course available through Zero Suicide Institute, the American Academy of Pediatrics has developed Counseling for Access to Lethal Means for Pediatric Providers. 

Consider the following points when discussing lethal means safety with parents and caregivers:

• Encourage parents and caregivers to be aware of other homes (I.e. family, friends) where youth may spend time and have access to firearms, medications or other means for suicide
• Ask youth and caregivers separately about access to firearms; youth may not be aware of firearms or medications in the home
• Stress that youth can be resourceful and have information available to them via the internet. Adults sometimes underestimate youth understanding of lethal means, including how to use a firearm

How to Support Parents, Caregivers and Other Adult Supporters

For generations and even in some cultures today, suicide is a taboo topic that is often not discussed or is enshrouded in stigma and misunderstandings. An important first step when working with parents and caregivers is to provide education about how to recognize warning signs of suicide, how to offer support to young people, how to advocate for their needs with schools and other community providers, and how to access professional help.  Below are two resources that can help inform adult supporters of suicidal youth:

• Not My Kid from the Society for the Prevention of Teen Suicide
• Teens and Suicide: What Parents Should Know from the American Foundation for Suicide Prevention

It is also important to encourage parents to seek out their own therapy or counseling for the family unit to promote help and healing for siblings who may be emotionally affected by a young person’s suicidal thoughts or behaviors.  Where available peer family support can be particularly helpful to navigate family challenges related to a child’s suicidality.

REMINDER: Visit the Zero Suicide Toolkit for additional information and resources.

TREAT Defined

Treat suicidal thoughts and behaviors using evidence-based treatments.  

In a Zero Suicide approach, people experiencing suicide risk, regardless of age, receive treatment to address the suicidal thoughts and behaviors directly. The Substance Abuse and Mental Health Services Administration (2020) identifies six evidence-based treatments and interventions for suicidality in youth¹:

• Dialectical Behavior Therapy (DBT)
• Attachment-Based Family Therapy (ABFT)
• Multisystemic Therapy-Psychiatric (MST-Psych)
• Safe Alternatives for Teens and Youth (SAFETY)
• Integrated Cognitive Behavioral Therapy (I-CBT)
• Youth-Nominated Support Team-Version II (YST-II)

To learn more, view the report, Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth.

Another promising intervention is CAMS-4Teens. In the first open clinical trial exploring the feasibility of using the Collaborative Assessment and Management of Suicidality (CAMS) framework with adolescents, results indicated effectiveness in reducing suicidal thoughts². To learn more about this intervention, visit the CAM-Care website for two online courses: CAMS-4Teens Interactive Training and CAMS-4Teens & Parents.

Considerations for Treating Young Children with Suicide Risk

In general, the evidence-based treatments referenced in the Zero Suicide toolkit have not been tested with preadolescent children. However, a review of 136 children ages 5-11 who died by suicide between 2013 and 2017 suggests that treatment for suicidality should also include support for mental health challenges, family and school-related concerns, and trauma³. This study found that:

• Nearly one-third of children experienced a mental health challenge at the time of their death
• 27% experienced a trauma (i.e. confirmed or suspected abuse or neglect, domestic violence, death of a family member or friend), and 40% of those experienced multiple traumas
• Bullying was suspected or confirmed in 18% of deaths
• Nearly 40% of children experienced one or more family challenges, including divorce or custody issues, legal problems, parental substance use, psychological problems, or suicide and, in nearly 60% of those cases, the result was children living in single-parent homes or with another family member
• School-related problems were identified in over 35% of cases, including suspension and expulsion, a change in schools, and a history of special education needs
• Children were disciplined on the day of their suicide in about one-third of cases and, in those situations, 34% were related to school, and 39% involved an argument with a parent or caregiver

Considerations for Working with Families and Caregivers

It is important to engage families in the treatment process for several reasons. Children and youth will benefit from the emotional support of parents and others, providing reminders and encouragement to use their safety plan. Practical support is also needed to promote suicide safety regarding lethal means and to access care (i.e. financial support, transportation). There may be barriers to treatment that should be discussed and attempts made to mitigate these challenges when developing a youth’s suicide care plan. As noted above, family-related concerns are sometimes a risk factor for suicidality. In these instances, Attachment-Based Family Therapy can help support the wellbeing of the entire family and repair or build secure parent-child bonds.

Attachment-Based Family Therapy (ABFT) is a process-oriented, emotion-focused approach designed to treat depression, and suicidal thoughts and behaviors in adolescents. ABFT uses a manualized treatment model that includes five sequential clinician-led tasks (Relational Reframe; Adolescent Alliance; Parental Alliance; Attachment; Autonomy Promoting) over 12 to 16 weeks (10-20 sessions).  It has been used in multiple settings and with youth ages 12-25 with diverse gender, sexual, racial, and cultural identities1. 

Considerations for schools

Therefore, schools play an important role in educating youth about mental health, normalizing open, and transparent conversations among students and staff, and promoting help-seeking behaviors. Population-based interventions that help children and youth develop positive coping strategies and emotion regulation have been shown to be effective at reducing suicide⁴.  Below are some examples of school-based programs and curricula:

• The Good Behavior Game aims to create a positive classroom environment by reducing aggressive and maladaptive behaviors, common risk factors for lower academic achievement and unhealthy later-life behaviors, such as tobacco, alcohol, and drug use.
• Signs of Suicide teaches students to identify signs of depression and suicide in themselves and others, as well as help-seeking behaviors.
• DBT Steps-A is a manualized approach to teaching DBT skills to students in grades 6-12 through the development of behavioral skills, such as mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation.

Finally, schools should consider the cultural identities of students and families when identifying universal prevention and intervention programs.  For example, American Indian Like Skills is a program designed to teach communication, problem-solving, stress management, anger regulation, and help-seeking skills while addressing issues relevant to American Indian/Alaska Native youth.

REMINDER: Visit the Zero Suicide Toolkit for additional information and resources.

 ___________________________________________________________________

1 Substance Abuse and Mental Health Services Administration (SAMHSA).  Treatment for Suicidal Ideation, Self-harm, and Suicide Attempts Among Youth. SAMHSA Publication No. PEP20-06-01-002 Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, 2020.

2 Adrian, M., Blossom, J.B., Chu, P.V., Jobes,. D, & McCauley, E. (2021). Collaborative Assessment and Management of Suicidality for Teens: A Promising Frontline Intervention for Addressing Adolescent Suicidality. Practice Innovations, 7(2), 154-167 

3 Ruch, D.A., Heck, K.M., Sheftall, A.H., Fontanella, C.A., Stevens, J., Zhu, M., Horowitz, L.M., Campo, J.V., & Bridge, J.A. (2021). Characteristics and Precipitating Circumstances of Suicide Among Children Aged 5 to 11 Years in the United States, 2013-2017.  JAMA Network Open, 2021 Jul 1; 4(7).   

4 Ackerman, J.P. & Horowitz, L.M. Youth Suicide Prevention and Intervention: Best Practices and Policy Implications. SpringerBriefs in Psychology: Advances in Child and Family Policy and Practice, 2022. Available at https://link.springer.com/book/10.1007/978-3-031-06127-1.

TRANSITION Defined

Transition individuals through care with warm hand-offs and supportive contacts.

Organizational policies that guide thoughtful and collaborative care transitions between levels of care and across community partners are a cornerstone of the Zero Suicide framework. Policies and protocols intentionally involve and support parents and caregivers, as youth are often dependent on adults to provide practical and logistical help to access suicide care.

Working with Multiple Systems

Children and youth often interact with multiple systems, such as healthcare, behavioral health, education, child welfare, and juvenile justice. Special attention should be given to policies that support communication and collaboration across various settings. 

Communication is an important and often overlooked factor in the referral process involving screening, assessment, and treatment. For example, when a child screens positive in the pediatrician’s office for suicide and is referred to a behavioral health provider for risk assessment, care should be taken to communicate results and treatment recommendations back to primary care. 

Similarly, communication should be shared between health providers, schools, foster care, and other systems when youth are in treatment for suicide care. While families may initially be hesitant to share what is often seen as “private” information, anyone involved in the care or support of a young person can help promote their safety and wellbeing. One way to encourage open dialogue is through psychoeducation and stigma reduction efforts that help to normalize discussions about mental health and suicide prevention in settings where families and children are served.

Caring Contacts

A common transition strategy is non-demand caring contacts. When designed for children and youth, the messages and imagery should be relevant to their interests and identities and be shared directly with the young person rather than sent to parents or caregivers. Consider engaging youth in developing these messages. Artwork for cards or digital design of electronic media can be created by youth in local schools, community art programs, or treatment programs.

Visit the Care Transitions Podcast Series for two episodes focused on youth and families to learn more about caring contacts and other care transition strategies:

• Family Perspectives on Care Transitions
• Caring Contacts Innovation: Reaching Youth after Hospital Care

REMINDER: Visit the Zero Suicide Toolkit for additional information and resources.

IMPROVE Defined

Improve policies and procedures through continuous quality improvement.

The Zero Suicide framework includes a data-driven quality improvement approach that assesses two main categories: fidelity to the essential systems, policy, and care components and; care outcomes.  Continuous quality improvement can only be effectively implemented in a safety-oriented, "just culture” free of blame for individual clinicians when someone with whom they are working attempts to end their life or dies by suicide.

The Zero Suicide Data Dashboard was designed to assist health and behavioral healthcare organizations in developing a data-driven, quality improvement approach to suicide care.

Within organizations, implementation success is supported by:

• Evidence-based tools and practices that are sensitive to the culture and needs of the youth and family
• Workflow structures appropriate to the patient population and setting
• Input from staff and individuals with lived experience
• Communication and collaboration with all systems in which the individual is engaged.
• Documentation, data collection, and review.

Consider using a quality improvement framework such as the Plan-Do-Study-Act cycle to pilot changes and improvements, review effectiveness, and adjust when needed. For more information, read Part V: Improving Quality of Suicide Care Across Systems in Youth Suicide Prevention and Intervention: Best Practices and Policy Implications. View our video, Responding as a System: Zero Suicide at Nationwide Children’s Hospital to learn more about successful implementation in a youth-serving system.

Engaging Communities to Support Sustainability

Children and youth are often in contact with multiple systems. Therefore, successful implementation of Zero Suicide may require enhanced relationships with community organizations to share information, reduce barriers to care, and develop protocols to support continuity of care. Formal agreements can provide a framework for collaboration (see sample Memorandum of Understanding from Centerstone of Tennessee).

Postvention

Exposure to suicide death—whether it’s a family member, friend, or role model—is a known suicide risk factor for children and adolescents. Youth are particularly susceptible to the negative effects of a suicide loss due to their developmental stage and social influences¹. When working with children and families, attention to postvention is critical—offering support and healing for those impacted, and enhanced intervention to identify others who may be more vulnerable to risk or who are already on the suicide care pathway. This is also important when working with schools and youth-serving systems.

The Suicide Prevention Resource Center and the Education Development Center collaborated with the American Foundation for Suicide Prevention to create postvention guidance for schools, titled After a Suicide: A Toolkit for Schools. Elements of the toolkit can be modified to support postvention efforts in other community settings. Children, Teens, and Suicide Loss offers practical strategies to support families and children bereaved by suicide, including how to manage conversations about suicide, a return to school, and wellness of caregivers and supporters.

REMINDER: Visit the Zero Suicide Toolkit for additional information and resources.

_____________________________________________________________

¹ Diefendorf, S., Van Norden, S., Abrutyn, S., & Mueller, A. (2022). Understanding Suicide Bereavement, Contagion, and the Importance of Thoughtful Postvention in Schools. In Ackerman. J.A., & Horowitz, L.M. (Eds.) Youth Suicide Prevention and Intervention: Best Practices and Policy Implications (pp.51-60).Springer. Available at https://link.springer.com/book/10.1007/978-3-031-06127-1

Conclusion

Despite the rising rates of suicide in children and youth, there are critical opportunities to identify and respond to this risk in health and behavioral health settings, and across children and youth-serving systems. While not unique to prevention efforts for children and youth, it is important to attend to the social determinants of health and familial impact that both contribute to and mitigate risk. Implementing the Zero Suicide framework when working with children and youth requires collaboration between multiple systems and effectively engaging families and other caring adults.

The Promise of Zero Suicide

Emergency departments, outpatient mental health specialty and pediatric primary care physicians constitute the most prevalent settings in which youth are seen prior to death1. Emergency department visits secondary to suicidal ideation and behavior have increased dramatically in recent years. Combined with shortages in child psychiatry and outpatient mental health care for youth, as well as limited inpatient psychiatric programs, extensive boarding in emergency departments has become commonplace in many areas of the country. The need for more effective approaches to address suicide risk in these health settings is clear. 

Emergency departments, mental health care systems, and pediatric primary care are also settings amenable to practice change consistent with the Zero Suicide framework. Understanding that effective youth suicide prevention necessitates a comprehensive approach that bridges health systems, schools, and communities further lends support to the application of Zero Suicide with these populations. 

Numerous children and youth-serving systems across the country have effectively adopted the Zero Suicide framework, developing exemplar care pathways specifically for use with pediatric populations that incorporate the use of validated tools, best practices, and the necessary integration with the support systems crucial for effective suicide prevention with youth. Driving innovation in health technology, pediatric health systems have also demonstrated the capacity for electronic health records to advance Zero Suicide implementation with fidelity, seamlessly capturing the data necessary for the continuous quality improvement philosophy of the framework. While the systems transformation needed for effective youth suicide can present challenges, comprehensive approaches to preventing youth suicide are imperative to saving lives. 

As the nature of suicide behavior and risk evolves, a variety of effective interventions may be needed to fit the developmental needs of the youth and family. Cognitive development, learning style, and emotional intelligence vary greatly across youth, families, and the broader developmental trajectory of childhood. Research into suicide-specific psychosocial interventions is also demonstrating important nuances in efficacy across outcomes. For example, some treatments have a more robust impact on suicide attempt behaviors, while others more strongly influence ideation. Additional factors to consider when exploring treatment options for youth include the efficacy of engaging the family and contextual system, promotion of resilience and protective factors, and reduction of risk factors at individual, family, and community levels.

While there is undoubtedly great need for further research, Zero Suicide offers a flexible and promising approach to reducing suicide in children and youth. The ability to engage youth and bridge gaps between support systems, schools, health care systems, and community providers is a critical feature of any promising approach to prevention. By addressing suicide-specific care from a comprehensive framework, Zero Suicide is well-suited to bridge the many systems and contextual factors needed to effectively address the complex challenge of youth suicide. 

Preventing Youth Suicide Collaborative

The Zero Suicide Institute would like to thank the Cardinal Health Foundation and the Children’s Hospital Association for their ongoing support of the Preventing Youth Suicide Collaborative. The following hospitals are members of the collaborative:  

2020 Pilot

• Akron Children’s Hospital
• Ann & Robert H. Lurie Children's Hospital of Chicago
• Arkansas Children's Hospital
• Children’s Hospital of Philadelphia
• Cincinnati Children’s Hospital Medical Center
• Dayton Children’s Hospital
• Nationwide Children’s Hospital
• ProMedica Russell J. Ebeid Children’s Hospital
• UH Rainbow Babies & Children’s Hospital

2022-2024 

• Atrium Health Levine Children's 
• Children's Health of Orange County 
• Children’s Memorial Hermann Hospital 
• Children's Mercy Kansas City 
• Children’s Nebraska
• Connecticut Children's 
• C.S. Mott Children's Hospital, Michigan Medicine 
• Le Bonheur Children’s Hospital
• Nicklaus Children's Hospital 
• Pediatric Mental Health Institute, Children's Hospital Colorado 
• Phoenix Children's Hospital 
• Saint Louis Children's Hospital
• Seattle Children's Hospital 
• UCSF Benioff Children's Hospitals 
• Valley Children's Healthcare 
• Yale New Haven Children's Hospital 

2023-2025 

• Advent Health for Children 
• Advocate Healthcare 
• Boston Children's Hospital 
• Children's Minnesota 
• Children's Wisconsin 
• Cohen Children's Medical Center a Division of Long Island Jewish Medical Center 
• Doernbecher Children's Hospital 
• Mary Bridge Children's Hospital 
• Medical University of South Carolina 
• Monroe Carell Jr. Children's Hospital at Vanderbilt 
• Pennsylvania State University—Penn State Children's Hospital 
• Primary Children's Hospital 
• Stanford Children's Health / LPCH Stanford 
• Wolfson Children's Hospital 

• 1

  Ahmedani, B.K., Simon, G.E., Stewart, C., Beck, A., Waitzfelder, B.E., Rossom, R., Lynch, F., Owen-Smith, A., Hunkeler, E.M., Whiteside, U., Operskalski, B.H., Coffey, M.J., and Solberg, L.I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870-7. doi: 10.1007/s11606-014-2767-3.