By Dr. Kathleen K. Miller, MD (Pediatric and Adolescent Medicine Expert Witness)
Case (minor details changed to protect patient’s identity): A 13-year-old-girl presents for a well visit at her pediatrician’s office. She has a history of anxiety and depression, and discloses self-harm via cutting herself with a razor. Her pediatrician refers her to the emergency department (ED). At the ED, she is seen by the attending physician and a social worker. The social worker and attending physician both interview her alone. She endorses daily passive suicidal ideation without a plan. The ED physician and social worker recommend outpatient management, and she is referred to psychiatry and encouraged to see her therapist. Three days later, she attempts suicide via overdose on medications. She is found unresponsive by her parents, who call EMS. She is admitted to the pediatric ICU and placed on a ventilator. While she eventually recovers enough to be taken off the ventilator, she had suffered brain damage from her overdose. Her parents sue the hospital system, claiming that her risk of suicide should have been recognized by the providers she saw in the ED.
This case highlights the high stakes surrounding pediatric suicide risk and raises a question that comes up often in pediatric malpractice claims: what does the standard of care actually require when a young patient presents with suicidal ideation?
As a pediatrician and adolescent medicine specialist, I find that this case includes many of the elements of my specialty that are the most stressful. Primary care providers are on the frontlines of treating most patients with anxiety and depression, often in the setting of short visits, severely ill patients, and limited access to mental health specialists. The stakes are even higher when caring for pediatric patients, who face unique challenges and are dependent on others for access to care. Depression, anxiety, and suicide attempts are all rising in young people, and have reached unprecedented levels in recent years. One in four young people report suicidal ideation within the past year, and the prevalence of lifetime suicide attempts in adolescents is an astonishing 4% in the United States.
Appropriately identifying, triaging, and managing a patient with suicidal ideation requires finesse and familiarity with available resources. In this review, we will walk through the standard of care in managing a young patient with suicidal ideation.
In This Article
Who should be screened for suicidal ideation and depression?
Briefly: everyone. All patients 12 and up should receive annual depression screening at their well visits. Screenings should be performed more frequently in adolescents with chronic medical conditions, other mental health conditions like ADHD or anxiety, or adolescents experiencing psychosocial stressors such as homelessness.
How should screening be done?
Standardized screening tools such as the Patient Health Questionnaire – Adolescents (PHQ-A) should be used for all patients at least annually. If a patient screens positive, then additional conversations and screening should take place.
What steps should be taken (and documented) in a patient with suicidal ideation?
If suicidal ideation is identified, the adolescent should be interviewed alone. Suicidal ideation (SI) can be divided into two broad categories: passive SI, and active SI. In passive SI, a patient may endorse feelings such as feeling they would be better off dead, wishing they weren’t alive, or fantasies about dying. In active SI, a patient may endorse a plan to commit suicide or intent to commit suicide. While passive SI should be taken seriously, active SI is considerably more alarming and may merit referral for a higher level of care. Patients should thus be asked if they have a plan to commit suicide or harm themselves, and if identified, details about that plan. There are additional validated tools, such as the Columbia Suicide Severity Rating Scale (C-SSRS) which helps assess the severity of SI and identify next steps.
All adolescent patients should also be interviewed alone, separately from their caregivers. “Alone time” with adolescent patients encourages teen patients to honestly report their concerns, including mental health concerns. We are unlikely to get the complete story from an adolescent patient if the parent is present. Failure to talk to an adolescent alone who is presenting with mental health concerns would not meet the accepted standard of care in adolescent medicine or psychiatry.
Failure to talk to an adolescent alone who is presenting with mental health concerns would not meet the accepted standard of care in adolescent medicine or psychiatry.
In all pediatric and adolescent patients with SI, a discussion should take place with the adolescent and caregivers about safety planning and means reduction. This should include reviewing emergency mental health resources and ensuring that crisis numbers are readily available. Means reduction, sometimes called means restriction, is an evidence-based strategy to reduce or eliminate access to lethal means of suicide. This may include a recommendation to remove firearms from the home (either permanently or temporarily), locking up medications (especially high-risk medications), or restricting access to knives or razors. This is especially important in adolescents, who have a relatively underdeveloped prefrontal cortex (the part of the brain that manages executive planning and decision-making) relative to adults. Making a suicide attempt harder, even by delaying it for the few minutes it can take to find a key to unlock a medication box or gun safe, can give adolescents’ prefrontal cortex a chance to kick in and result in a different, safer decision.
Making a suicide attempt harder—even by delaying it for the few minutes it can take to find a key—can give an adolescent’s prefrontal cortex a chance to kick in and result in a different, safer decision.
Why wouldn’t every pediatric patient with suicidal ideation be referred to see psychiatry?
In short: lack of resources. Urgent referrals to psychiatry are, in most systems, unavailable, and patients are referred to the ED, as in the case above. Unfortunately, referring a patient to the ED for SI is not without risk. There are long wait times, and a patient may have to “board” in the ED for several days while waiting for inpatient bed placement in a psychiatric facility. The longest I’ve had a patient board in the ED for mental health concerns is 10 days, but there are horror stories of patients who have had to wait much longer. Outcomes for patients who are seen in the ED may not necessarily be better than patients who can be managed on an outpatient basis. ED visits also incur additional cost, which can create family stress and worsen the overall situation for patients living in poverty. ED visits can also be traumatic for patients experiencing acute mental health crises, and a bad experience can deter patients from seeking psychiatric care in the future. In general, if pediatricians and adolescent specialists can get away with managing a patient WITHOUT sending them through a painful process in the ED, we will try to do so. However, when managing pediatric suicide risk, we walk a fine line in trying to make sure our patients are safe, while also trying to get them care in the most trauma-informed and accessible way.
How do you decide who gets to go home with SI, and who should be admitted to inpatient psychiatry or the hospital?
Many factors are considered.
Things that might lead us to consider outpatient management include:
- A supportive family who has reliably attended follow-up visits and is well-known to the practice.
- No prior history of suicide attempts.
- The patient is already established with a therapist and/or psychiatrist.
- The family is willing to participate in means reduction.
Factors that might lead us to push for inpatient psychiatry:
- A history of prior suicide attempts or impulsivity.
- Parents who are not engaged and/or struggle to take their child’s mental health seriously.
- The patient is new to the practice or has a history of missing appointments and/or referrals.
- Limited or no access to outpatient therapist or psychiatrist.
- A significant underlying mental health history or trauma history.
- An immediate need to adjust medications rapidly under medical supervision.
The case in this article is, to be frank, one of my biggest fears and worst nightmares. As pediatricians, we care very deeply about our patients, and we want to keep them safe and healthy. One of the reasons why suicide is so scary is because we simply cannot always keep our patients safe from this risk. Not all suicide attempts are preventable: an estimated 20% of suicide attempts are not associated with psychiatric disease, and may reflect impulsivity or devastating life events.
Did the documentation reflect a reasoned risk assessment, weighing factors like prior attempts, family engagement, and access to outpatient care, rather than a generic disposition?
Case screening questions for attorneys
When evaluating a pediatric suicide attempt case, these are the questions I look at first:
- Was a validated screening tool, such as the PHQ-A or C-SSRS, used and properly documented? Absence of a standardized tool in the chart is itself often a discovery point.
- Was the adolescent interviewed alone, separate from caregivers? Failure to do so falls below the accepted standard in adolescent medicine and psychiatry.
- Was a safety plan discussed and documented, including specific means reduction steps such as securing medications or firearms?
- Were referrals appropriate given the resources available, and was the discharge plan something the family could realistically follow through on?
- Did the documentation reflect a reasoned risk assessment, weighing factors like prior attempts, family engagement, and access to outpatient care, rather than a generic disposition?
These five questions focus on standard of care. Causation is a separate legal question that often requires additional expert analysis.
In this case, I’m glad to report that the patient survived. While she experienced a hypoxic brain injury from the overdose, her neurologic function improved over the following years to the point that she was able to return to school and extracurricular activities.
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About the Author
Dr. Kathleen Miller, MD, is an Assistant Professor of Pediatrics at the University of Minnesota and a physician at Boynton Health. Formerly the Medical Director of Adolescent Medicine at Children’s Minnesota, she is a peer-nominated Castle Connolly Top Doctor specializing in adolescent mental health, trauma, and complex primary care. An accomplished researcher with over 20 peer-reviewed manuscripts, her expert commentary has been featured by The New York Times, NPR, and BBC World News.
Contact Dr. Miller:
Email: [email protected]
Phone: (651)441-2196