Clinical Pearls Video

Aggression and Behavioral Dysregulation (Nasuh Malas, M.D., M.P.H.)

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Alyssa Wealty |

Apr 15, 2024

Aggression and Behavioral Dysregulation

Clinical Pearls Video Series

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

Assessment
- How do we think about aggressive behavior and how does it present? (0:08–2:33)
- What risk factors contribute to aggression? (2:35–3:10)
- What factors should be considered when assessing aggression? (3:11–4:50)
- How do I effectively communicate to the patient and family about aggression and understand how family dynamics can contribute to aggression risk? (4:52–10:00)
- How do I conduct an evaluation of youth at risk for aggression? (10:00–14:10)
Management
- How can I partner with schools and community resources in supporting a child who has aggressive behavior? (14:12–16:15)
- What types of environmental, family, and therapy strategies can I suggest to help stem aggressive behavior? (16:17–20:25)
- How and when do I think about using medications to manage aggression? (20:26–25:02)
Key Takeaways (25:03–26:12)

Presenter

Nasuh Malas, M.D., M.P.H., Child & Adolescent Psychiatrist, University of Michigan

Synopsis

Children and adolescents frequently manifest agitation or aggressive behavior that puts themselves or others at risk. Worsening behaviors, agitation, and aggression are one of the most common reasons families seek care in primary care offices and emergency care settings. It is also one of the top reasons a child is removed from the school setting. Nationally, 15% of youth in the emergency room require physical restraint, and as many as 23% of youth with Autism Spectrum Disorders (ASD) treated in the emergency room are restrained or sedated.

If not addressed early and often, agitation can further escalate, leading to delays in care, increased health care utilization, safety concerns, and poor outcomes, while creating an unsafe, distressing care environment for patients, families and staff. This presentation will review key aspects of the assessment and management of escalating behaviors, agitation, and aggression in the pediatric patient.

Resources & Screening Tools

Resources Mentioned in the Video

Emergency Medical Services for Children, Pediatric Education and Advocacy Kit: Agitation: https://emscimprovement.center/education-and-resources/peak/pediatric-agitation/
The REACH Institute, Treatment of Maladaptive Aggression in Youth Toolkit: http://www.t-may.org
American Academy of Child and Adolescent Psychiatry’s Outbursts, Irritability and Emotional Dysregulation Resource Center: https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Emotional_Dysregulation/Home.aspx?hkey=e8775b31-1ec9-4cd2-82c1-a28c658fda39&WebsiteKey=a2785385-0ccf-4047-b76a-64b4094ae07f

Screening Tools

Although there are no validated screening tools for risk of aggression in youth in the primary care setting, there are screeners that may help you identify potential factors contributing to aggression, including:

Substance use, including nicotine: CRAFFT 2.1 N+ https://crafft.org/wp-content/uploads/2021/07/CRAFFT_2.1N-HONC_Clinician_2021-07-03.pdf
Depression: Patient Health Questionnaire (PHQ-9): https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
Suicidality: Ask Suicide Screening Questionnaire (ASQ): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf
PTSD/Trauma: Safe Environment for Every Kid (SEEK): https://seekwellbeing.org/seek-materials/ (requires license)
PTSD/Trauma: Pediatric Traumatic Stress Screening Tool (PTSST): https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529796906
Anxiety: Screen for Childhood-Related Disorders Scale (SCARED): https://www.aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/symptoms/ScaredChild.pdf
Anxiety: Generalized Anxiety Disorder screener (GAD-7): https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf
ADHD: Vanderbilt (Parent and Teacher Informant Scales): https://nichq.org/sites/default/files/resource-file/NICHQ-Vanderbilt-Assessment-Scales.pdf

Other Resources

MC3 Recordings:
- Evaluation and Management of Youth at Risk for Agitation or Aggression, by Nasuh Malas, M.D., M.P.H.
- Treating Disruptive and Aggressive Behavior in Youth, MC3 ECHO: Behavioral Health, by Zakia Alavi, M.D.
Pediatric Meltdown Podcast Episodes:
- Tantrums, Difficult Behaviors, “Red Alerts”: Using the “Smart Brain” for Problem Solving (Episode 133)
- Understanding Aggressive Behaviors: Who, What, Why, When and Where (Episode 137)
Breaking Down Mental Health Podcast Episodes:
- Aggression Management – Pharmacological Interventions
- Aggression Management – Nonpharmacological Interventions

References

Gerson R, Malas N, Mroczkowski MM. Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents. Child Adolesc Psychiatr Clin N Am. 2018;27(3):367-386. https://doi.org/10.1016/j.chc.2018.02.002

Malas N, Spital L, Fischer J, Kawai Y, Cruz D, Keefer P. National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings. Psychosomatics. 2017;58(3):299-306. https://doi.org/10.1016/j.psym.2017.01.009

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019;20(2):409-418. https://doi.org/10.5811/westjem.2019.1.41344

Curry A, Malas N, Mroczkowski M, Hong V, Nordstrom K, Terrell C. Updates in the Assessment and Management of Agitation. Focus (Am Psychiatr Publ). 2023;21(1):35-45. https://doi.org/10.1176/appi.focus.20220064

Connor DF, Newcorn JH, Saylor KE, Amann BH, Scahill L, Robb AS, Jensen PS, Vitiello B, Findling RL, Buitelaar JK. Maladaptive Aggression: With a Focus on Impulsive Aggression in Children and Adolescents. J Child Adolesc Psychopharmacol. 2019;29(8):576-591. https://doi.org/10.1089/cap.2019.0039

Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)

Aggression and Behavioral Dysregulation Quiz

1. Which of the following factors should be the primary driver for the choice of medication to manage agitation or aggression in youth?

Patient age

Provider familiarity with the medication

Route of medication delivery

Underlying etiology driving presentation

Onset of medication action

The correct answer is the underlying etiology driving presentation.

Although all of these are important considerations in the medication management of agitation or aggression in youth, the underlying etiologic factors that are driving the agitation are most important. Managing these factors will mitigate progression of the behavior,and also address the underlying cause of the escalation in the behavior.

2. Which of the following statements is most true about agitation?

It occurs abruptly without any precipitating factors

It cannot be measured

It occurs along a spectrum of cognitive, emotional, and behavioral changes

It primarily is managed by mental health professionals

It often requires the use of medications to ensure patient and staff safety

The correct answer is it occurs along a spectrum of cognitive, emotional, and behavioral changes.

Agitation often has many precipitating factors that cause a child or adolescent to go from a calm state to an agitated state. Agitation can be screened for and monitored over time. Commonly, these patients are managed by primary care providers, school personnel, and other non-mental professionals, with only a small proportion being directly managed by mental health professionals. Effective preventative measures and early intervention may include the use of environmental modification, behavioral planning and other psychotherapeutic interventions, which can mitigate the use of medications or avoid the use of medications altogether. Agitation does occur along a spectrum, with thoughts, emotions, and resulting behaviors being quite varied from patient to patient.

3. An adolescent presents to the hospital with a history of insulin-dependent diabetes, psoriasis, mild intermittent asthma and generalized anxiety disorder. At admission, the patient becomes irritable and argumentative and starts refusing treatment. Family notes this behavior is atypical for the patient. Which of the following is the next best step in the care of this patient?

Consult the mental health service

Contact security

Obtain laboratory investigation

Administer a benzodiazepine

Provide the patient with a fidget toy for distraction

The correct answer is that you should obtain laboratory investigation.

This case highlights how physical health may impact cognition, emotional regulation, and behavior in an adolescent with diabetes. Although many of these interventions may be needed, initially, it is important to understand the patient’s physical health status. The presentation of diabetic ketoacidosis, or another physical health factor contributing to changes in behavior may be a harbinger for clinical decompensation and can be an acute safety concern. Rapid physical health evaluation is needed in this case and should not be delayed.

4. What is the primary goal of medication management in the pediatric patient exhibiting aggressive behavior?

Sedation

Chemical restraint

Delaying further escalation until security presents

Limit setting

Tranquilization

The correct answer is tranquilization.

The primary goal of medication management in the pediatric patient exhibiting aggressive behavior is tranquilization, or calming of the patient, without sedation. This allows for the ongoing evaluation and management of underlying clinical factors influencing the presentation of aggression. Sedation is not the primary goal, and it can be harmful to the patient while limiting further assessment. It should be avoided when possible. Chemical restraint, or restricting an individual's freedom of movement through medications, is also potentially harmful, limits assessment, and should be avoided. Limit setting and other behavioral interventions are often achieved non-pharmacologically. The use of medications to delay the worsening of behavior may be a secondary goal or a consideration in the management of aggression but should not be the primary focus because it may result in delays in care and the use of more invasive or restrictive means of managing the patient’s aggression.

5. A child with seizure disorder, needle phobia, and attention deficit hyperactivity disorder presents to outpatient phlebotomy for a blood draw related to valproic acid levels. Upon entering the waiting room of the facility, the child begins to scream, thrash, and use vulgar language and attempts to bolt out into the parking lot. Which of the following is recommended as the best option to address this child’s aggressive behavior?

Providing the child a tablet with their favorite programming

Leave the phlebotomy office and reschedule the appointment when two caregivers can be present

Inform the child that if they become quiet they will not have to “get a shot”

Attempt to expedite the process by asking staff to carry and restrain the patient quickly to obtain the blood draw

Provide the child a low-dose benzodiazepine to calm while waiting for the blood draw

The correct is to provide the child a tablet with their favorite programming.

Providing the child with a soothing strategy is preferred, particularly one that will be enjoyable to the patient and distract them from the task at hand. The other options may worsen the behavior, carry more risk, be traumatic for the patient, or reinforce the behavior in the phlebotomy setting. Leaving the office may not result in a change in behavior, and may delay the needed testing. It can also reinforce the use of aggression to avoid being in the office, therefore strengthening the behavior. Suggesting that the child will not have “a shot” may engender mistrust and be traumatic. Expediting the process with restraint may be unsafe and further distress the patient the next time they attempt to get a blood draw. The use of a medication, while it might be needed in the future, is not the best next step in this situation. Thoughtful use of non-pharmacologic and environmental interventions may be more effective for this patient.

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Clinical Pearls Video

Trauma-Informed Care (Alyse Folino Ley, D.O.)

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Alyssa Wealty |

Mar 25, 2024

Trauma-Informed Care

Clinical Pearls Video Series

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

Assessment
- How do I ask about adverse childhood experiences (ACEs) without being intrusive? (0:31–2:28)
- What screening tools and language can I use to understand the potential exposure risk while creating a safe environment to talk about trauma? (2:31–4:01)
- What do I do if I suspect the caregiver is the perpetrator of abuse or neglect? (4:02–4:43)
- What are other signs or red flags that may suggest abuse or neglect is occurring to a child? How does this present across different age groups? (4:44–5:52)
- How can I make a busy practice more friendly to patients and families who may have experienced trauma or generational trauma? (5:52–8:19)
Management
- What therapies and medications can help the emotions, behaviors, and interpersonal conflict seen in youth with trauma or PTSD? (8:20–11:08)
- Where can I find resources for patients, families, my staff, and myself related to the manifestations and impact of trauma on youth and families? (11:09–12:14)
Key Takeaways (12:17–13:00)

Presenter

Alyse Folino Ley, D.O., Child & Adolescent Psychiatrist, Michigan State University

Synopsis

Traumatic events in childhood negatively impact mental and physical health across the lifespan. These adverse childhood experiences, or ACEs, are common but also preventable.

In the late 1990s, the Center for Disease Control and Kaiser Permanente surveyed 17,000 adults regarding ACEs. The ten ACEs initially researched included child abuse (physical, sexual, or emotional); household stressors/traumas (family violence, substance use, mental illness, divorce and/or incarceration of a family member); and neglect (emotional and/ or physical).
Researchers discovered over 64% of adults reported experiencing at least one of the negative events/trauma as children or adolescents and over 17% of individuals reported enduring four or more ACES prior to age 18.
The researchers also discovered that the more adverse experiences a person endured, the more likely they were to have poor physical and mental health outcomes as an adult, including cancer, cardiovascular disease, substance use disorders, depression, and early death.

Individuals who face or witness a life-threatening or traumatic event, serious injury, sexual violence, or learn of a family member who experienced such an event, are at risk of developing Post Traumatic Stress Disorder (PTSD).

Yearly, PTSD affects 3.5% of adults and 5% of youth in the U.S..
Approximately one in 11 individuals are diagnosed with PTSD during their life. The development of PTSD is dependent upon many factors, including, severity of the event, the nature of the event, the age of the child, a history of other psychiatric disorders, the ability to obtain help and support, and adults’ reactions.

ACEs are linked to an increased risk of chronic health conditions, mental health conditions, and substance use disorders, and decreased educational and vocational achievement.

PTSD can vary in severity from mild functional impairment to severe and can even become debilitating.
The neurochemical changes that take place during a traumatic event can hijack brain functioning, leaving an individual trapped in the fight or flight response.
Youth with PTSD have symptoms related to intrusive memories (nightmares, flashbacks), hyperarousal, avoidance, as well as mood and cognitive alterations.
Children and adolescents manifest their symptoms in different ways at different ages. Young children are more likely to reenact their trauma through play whereas older children and adolescents may present with suicidal ideation, somatic complaints, social withdrawal, detachment, disorganized, oppositional /defiant behavior, difficulties with concentration, aggression, anger outbursts, anhedonia, irritability, worries about safety, and fear of death.

Although traumatic events and adverse experiences increase an individual’s mental and physical comorbidities, individuals who have been traumatized often avoid seeking care. Avoidance behaviors and the stigma associated with pursuing psychiatric care often prevent individuals from obtaining the care they need.

Resources & Screening Tools

Resources Mentioned in the Video

The National Child Traumatic Stress Network: https://www.nctsn.org/
American Academy of Child and Adolescent Psychiatry, Facts for Families: https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Posttraumatic-Stress-Disorder-PTSD-070.aspx
American Academy of Pediatrics, Trauma Toolbox for Primary Care: https://www.aap.org/en/patient-care/foster-care/supporting-children-who-have-experienced-trauma/
Care Process Model: Diagnosis and Management of Traumatic Stress in Pediatric Patients: https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529796906
International Society of Trauma Stress Studies: https://istss.org/public-resources
American Psychiatric Association, What is Posttraumatic Stress Disorder (PTSD)? https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
CDC Fast Facts, Preventing Adverse Childhood Experiences: https://www.cdc.gov/violenceprevention/aces/fastfact.html
Veteran Affairs, National Center for PTSD: How Common is PTSD in Children and Teens? https://www.ptsd.va.gov/understand/common/common_children_teens.asp
National Sexual Violence Resource Center: https://www.nsvrc.org/
National Resource Center on Domestic Violence: https://www.nrcdv.org/
RAINN Hotline: 1-800-656-HOPE(4673): https://rainn.org/about-national-sexual-assault-telephone-hotline
Michigan Department of Health and Human Services Trauma-Informed Care Programs and Policy Initiatives: https://www.michigan.gov/mdhhs/adult-child-serv/childrenfamilies/tts/btim/mtisppi

Screening Tools

PTSD/Trauma: Safe Environment for Every Kid (SEEK): https://seekwellbeing.org/seek-materials/ (requires license)
PTSD/Trauma: Pediatric Traumatic Stress Screening Tool (PTSST): https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529796906
Anxiety: Screen for Childhood-Related Disorders Scale (SCARED): https://www.aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/symptoms/ScaredChild.pdf
Anxiety: Generalized Anxiety Disorder screener (GAD-7): https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf
Depression: Patient Health Questionnaire (PHQ-9): https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
Suicidality: Ask Suicide Screening Questionnaire (ASQ): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf
Suicidality: Columbia Suicide Severity Rating Scale (CSSR-S): https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf

Other Resources

MC3 Recordings:
- Trauma in Young Children: Part 1, Sheila Marcus, M.D.
- Trauma in Young Children Part 2: Screen and Responding, by Kate Rosenblum, Ph.D.
Pediatric Meltdown Podcast Episodes:
- Trauma and Resilience: Affiliate! (Episode 93)
- Trauma and Resilience: “Connect Before You Correct” (Episode 128)
Breaking Down Mental Health Podcast Episode:
- Trauma Informed Care (Episode 7)

References

Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2946114/

Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2

Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)

Trauma-Informed Care Quiz

1. Which of the following statements is true regarding screening for ACEs?

ACEs should be discussed with patients only if there is a history of past abuse

A history of ACES increases risk of later physical and mental conditions in adulthood

Screening for ACEs may induce a trauma reaction

If a patient screens positive for 4 or more ACES, they qualify for a diagnosis of PTSD

Screening for ACES is not indicated in the primary care setting as they are often not preventable

The correct answer is that a history of ACES increases risk of later physical and mental conditions in adulthood.

ACEs should be routinely discussed with all patients and not just patients with past abuse, neglect, or other traumatic events. Screening does not cause trauma but rather is helpful in identifying patients at high risk for psychological stress that is progressively worsening and may lead to PTSD. The number of ACEs experienced is not diagnostic of PTSD, but rather PTSD is the presence of hypervigilance, avoidance, and re-experiencing for more than 1 month following a traumatic event or experience. ACEs are often preventable and should be proactively identified and addressed. Screening for ACEs can be very helpful in identifying patients at risk for future pathology or development of PTSD and is encouraged to be conducted and may be conducted universally.

2. Which of the following is contraindicated in the treatment of PTSD?

Debriefing

Exposure Therapy

Treatment with SSRIs

Caregiver involvement

Engagement in support groups

The correct answer is debriefing.

Debriefing, or the practice of reviewing the traumatic events in detail and the associated emotional response, has been found to be worse than controls or education only resulting in a worsening risk of PTSD, as well as risk of depression, anxiety, and other psychological sequelae of trauma. All the other answers are effective, or can be effective, in managing PTSD in youth.

3. Which of the following is considered first-line in the treatment of comorbid psychiatric and behavioral symptoms of PTSD?

Supportive Therapy

Debriefing

Cognitive Behavioral Therapy

Interpersonal Psychotherapy

Habit Reversal Therapy

The correct answer is cognitive behavioral therapy.

Cognitive behavioral therapy is the first-line treatment of comorbid psychiatric and behavioral symptoms associated with PTSD. Debriefing is contraindicated in individuals with PTSD and the other therapies may be considered as augmenting therapies for specific comorbidities but not first-line therapies. Medications may also be considered for management of psychiatric comorbidities, but are also not considered first-line.

4. Which of the following medications may be helpful in the treatment of hyperarousal symptoms in PTSD?

Benzodiazepines

Alpha-2 agonist

Antihistamine

Atypical antipsychotic

Selective alpha-1 blocker

The correct answer is alpha-2 agonist.

Although all of the medications listed may be helpful in the management of psychiatric comorbidities of PTSD, or may aid with or augment symptom management, alpha-2 agonists target the noradrenergic and sympathetic response associated with hyperarousal in PTSD and have the most evidence to support its use for the management of hyperarousal in PTSD among youth.

5. Which of the following statements is true regarding the medication management of PTSD in children and adolescents?

Medications should not be started until children experience at least 2 or more ACEs

SSRIs can be used to prevent ACEs and may be prescribed proactively to at-risk populations

Benzodiazepines and atypical antipsychotic medications should be used to manage behavioral dysregulation associated with PTSD

SSRIs can be used to treat PTSD, as well as associated depression and anxiety

Frequent use of as-needed medications is recommended for symptom relief

The correct answer is that SSRIs can be used to treat PTSD, as well as associated depression and anxiety.

Use of medication should not be predicated on the number of ACEs but more on the severity of presentation, response to non-pharmacologic interventions, level of impairment, and comorbid psychiatric conditions. SSRIs cannot be used to prevent ACES, but rather other non-pharmacologic and environmental modifications and interventions can help mitigate this risk. Behavioral dysregulation is often best managed through psychotherapeutic and behavioral interventions, structured behavioral planning, with judicious use of medications with attempts made to limit exposure to benzodiazepines and antipsychotics when possible. Frequent reliance on as-needed medications may detract from the patient using more adaptive coping skills or working through their distress. Furthermore, the use of potentially habit-forming medications, like benzodiazepines, as needed frequently throughout the day during periods of distress can result in tolerance and dependence. SSRIs can be effective in managing the symptoms of PTSD, as well as comorbid anxiety, depression, and panic. SSRIs can be paired with psychotherapy, such as CBT (Cognitive Behavioral Therapy) to best support the patient with PTSD.

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Clinical Pearls Video

Substance Use Disorders (Joanna Quigley, M.D.)

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Alyssa Wealty |

Mar 11, 2024

Substance Use Disorders

Clinical Pearls Video Series

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

Assessment
- When should I start asking youth about their use, and is there an easy way to do that? (0:09–2:17)
- What screening tools can be used and how can they help identify risk? (2:18–4:55)
- I have a busy practice and wonder if there are strategies I can use that are time-limited when I start to notice initial or escalating use of nicotine or vaping, cannabis, and alcohol. (4:56–8:43)
- What if I identify youth with more significant substance use during the screening process? (8:43–10:00)
Management
- What can I do in a busy practice to help prevent substance use disorders in youth? Is there a communication style or approach that can help facilitate discussions about substance use and its treatment? (10:00–12:14)
- What does treatment look like and what type of therapies are provided? (12:15–13:28)
- What is the role of medications in substance use treatment? (13:29–15:38)
Key Takeaways (15:39–16:38)

Presenter

Joanna Quigley, M.D., Child & Adolescent Psychiatrist, University of Michigan

Synopsis

Substance-use-related morbidity and mortality continue to increase at an alarming rate. It is imperative to learn, understand, and practice prevention, screening, assessment, and management of youth at risk for substance use to stem this alarming rise in substance use and its sequelae in the pediatric population.

Substance use often starts in late childhood and adolescence, so these age groups are particularly important targets for prevention and early risk mitigation efforts.

The adolescent brain is still developing and adolescents can have variable levels of impulsivity, thoughtful planning, awareness of future risk, judgment, and risk-taking engagement.
Among youth surveyed in the 12th grade, most commonly youth initiated alcohol use in the 9th grade, and more than half initiated cannabis use in the 9th or 10th grade.
In addition to a rapid rise in alcohol and marijuana use, as well as the increased vaping and nicotine use, there are over 900,000 adolescents misusing opioids nationally.

Primary care can play a pivotal role in substance use prevention and promoting behavioral health interventions to mitigate the risk of substance use, as highlighted by professional associations like the American Academy of Pediatrics, the American Academy of Family Medicine, and the American Academy of Child and Adolescent Psychiatry.

Primary care providers have the unique advantage of establishing a trusting, long-term relationship with youth and families from early childhood through young adulthood and may be well positioned to observe changes in a child’s presentation suggest risk or progression of substance use.
Primary care providers do not need to guess or intuit substance use in their patients, as several short, validated screeners and tools exist to screen and assess youth for substance use risk, including tools like the CRAFFT and the AUDIT.
Specific recommendations have been made for primary care to routinely screen adolescents for substance use, conduct assessment for those that screen positive, provide brief evidence-based interventions, and refer to more intensive treatment or psychiatric care when needed.

Most youth will endorse no use of tobacco, alcohol, or marijuana, and the physician in those cases can play an important role by reinforcing that healthy choice and the benefits of never starting to use.

If use is detected, the integrated approach of substance use screening, brief intervention, and referral to treatment (SBIRT) can be utilized. SBIRT is an evidence-based practice used across multiple settings and age groups.
SBIRT allows clinicians to identify young people who are at risk for developing a substance use disorder and choose an appropriate and informed response.
In some cases, a brief intervention may be needed, and in the minority of more serious cases, the adolescent patient can be referred to more intensive and/or specialized treatment.

The unique access and influence pediatricians have on health behaviors throughout the early stages of life make them an essential point of intervention for adolescent substance use.

Resources & Screening Tools

Resources Mentioned in the Video

Screening, Brief Intervention, and Referral to Treatment (SBIRT): https://www.samhsa.gov/sbirt
American Academy of Pediatrics Clinical Report on Substance Use Screening, Brief Intervention, and Referral to Treatment (clinical workflow) https://publications.aap.org/pediatrics/article/138/1/e20161211/52568/Substance-Use-Screening-Brief-Intervention-and
Al-Anon family support: https://al-anon.org/
Use of Buprenorphine for opioid use disorder: https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/buprenorphine
American Academy of Pediatrics Training to Treat Opioid Use Disorder in Adolescents: https://www.aap.org/en/patient-care/substance-use-and-prevention/training-to-treat-opioid-use-disorder-in-adolescents/

Screening Tools

Substance use: Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT): https://crafft.org/
Substance use, including nicotine: CRAFFT 2.1 N+ https://crafft.org/wp-content/uploads/2021/07/CRAFFT_2.1N-HONC_Clinician_2021-07-03.pdf
Alcohol use: Alcohol Use Disorders Identification Test (AUDIT): https://auditscreen.org/
Depression: Patient Health Questionnaire (PHQ-9): https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
Suicidality: Ask Suicide Screening Questionnaire (ASQ): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf
Substance use: Screening to Brief Intervention (S2BI): https://www.samhsa.gov/resource/ebp/screening-brief-intervention-s2bi

Other Resources

MC3 Recording:
- Youth Substance Abuse, MC3 ECHO: Behavioral Health, by Joanna Quigley, M.D.
Pediatric Meltdown Podcast Episode:
- Substance Use Disorders and Childhood Exposures: What you need to know with Dr. Allek Scheele (Episode 5)

References

Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs. 2012;44(4):307-317. https://doi.org/10.1080/02791072.2012.720169

Hammond CJ, Gray KM. Pharmacotherapy for substance use disorders in youths. J Child Adolesc Subst Abuse. 2016;25(4):292-316. https://doi.org/10.1080/1067828x.2015.1037517

Levy SJL, Williams JF, Committee on Substance Use and Prevention, Ryan SA, Gonzalez PK, Patrick SW, Quigley J, et al. Substance use screening, brief intervention, and referral to treatment. The American Academy of Pediatrics. 2016;138(1):e20161211. https://doi.org/10.1542/peds.2016-1211

Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the future national survey results on drug use, 1975-2015: Volume I, secondary school students. https://eric.ed.gov/?id=ED578604

Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the future national survey results on drug use, 1975-2017: volume I, secondary school students. https://monitoringthefuture.org/wp-content/uploads/2022/08/mtf-vol1_2017.pdf

Schwee LH. Pediatric SBIRT: understanding the magnitude of the problem. J Trauma Nurs. 2009;16(3):142-147. https://doi.org/10.1097/jtn.0b013e3181b9e0ee

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-003, NSDUH Series H-56). Rockville, MD:Center for Behavioral Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/

Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)

Substance Use Disorders Quiz

1. When should screening for substance use begin in youth in the primary care setting?

Screening should start for all youth ages 12 and up

Screening should be targeted to youth presenting with primary behavioral health concerns

Screening should start for all youth ages 16 and up

Screening should be utilized at the discretion of the primary care provider based on clinical judgment as validated screeners do not exist for youth under age 18

Screening should not be done until adulthood given it may suggest use in youth who otherwise might not use

The correct answer is that current recommendations are to screen all youth ages 12 and up for substance use.

Several validated screeners exist to screen adolescents, including the CRAFFT and AUDIT. Screening does not increase substance use or cause adolescents to consider starting substance use but may identify substance use early, prevent use or mitigate worsening use or progression to a substance use disorder. Although youth with substance use disorder may have additional mental health comorbidities, many do not and so targeted screening only of youth with a primary behavioral health concern may result in many missed opportunities to identify at-risk youth and intervene early.

2. An adolescent presents for an annual sports physical. The parent pulls you aside and tells you they found vaping materials in the adolescent’s backpack and hopes you will discuss this with them. The parent smokes tobacco and doesn’t want the adolescent to develop the habit but states “kids experiment, right?” Which of the following statements is most accurate for this patient?

Vaping is common among adolescents and often passes without consequence

Using a screening tool may plant the thought of using substances in the patient’s mind

The parent’s nicotine use has little to no impact on whether the adolescent will use substances

Utilizing motivational interviewing will help engage the patient in discussing nicotine use

The parent and provider should meet with the patient together to inform the adolescent of all the risks of tobacco use and vaping

The correct answer is that motivational interviewing is an evidence-based communication framework to discuss health behavior change in adolescents, as well as adults.

It allows the provider to come alongside the patient where they are at and work with the patient to engage them in discussion regarding change and elicit motivations for change. Vaping in adolescents can result in sustained use and use of other substances. Screening is recommended in adolescents to identify risk early and address it early. Parental use of substances, including nicotine, portends higher risk of use and addiction in the adolescent. Meeting with the parent and providing information may be unhelpful if the patient is not engaged and is a style that may result in further resistance in the adolescent.

3. An adolescent you are treating for depression with sertraline asks you about the benefits of marijuana for sleep. The patient states that the sertraline has been helpful but they continue to have difficulties sleeping and says using marijuana “2 or 3 times a week helps”. The patient’s PHQ-9 score is 16 and the adolescent has some suicidal ideation but no previous attempts, and no plan. When asked about intent the patient says “I would never do that to my family.” Which of the following is the most important next step in the care of this patient?

Arrange for inpatient psychiatric hospitalization directly from the primary care office

Start a new selective serotonin reuptake inhibitor (SSRI) for depression

Prescribe N-acetylcysteine to decrease marijuana use

Refer the patient for cognitive behavioral therapy

Notify the patient’s parents immediately about the suicidal thoughts and marijuana use

The correct answer is that you should refer the patient for cognitive behavioral therapy.

In this case, the patient is currently on a selective serotonin reuptake inhibitor with benefit but is endorsing difficulties with sleep, ongoing depression, and passive suicidal ideation. There is no mention of concurrent, evidence-based psychotherapy and the addition of cognitive behavioral therapy (CBT) would be helpful for this patient. In addition, adjustment of the dose of the SSRI may be helpful, but switching to another agent would be premature and not the best approach, particularly since the patient indicated benefit on sertraline. Psychiatric admission is not indicated given the passive nature of the suicidal ideation and the lack of imminent suicidal risk or harm. N-acetylcysteine, given the frequency and nature of cannabis use, would not be the next best step in the care of this patient as other interventions, like CBT for sleep, depression, and substance use, would carry less risk and could be effective. Given the lack of imminent risk of harm and to maintain a good therapeutic alliance with the patient, disclosure of passive suicidal thoughts and marijuana use is not advised in this patient.

4. A patient in late adolescence comes in for examination before going to college in the fall. You screen for depression, suicidal ideation, and substance use using the PHQ-9, the Ask Suicide Screening Questions (ASQ), and the CRAFFT. The PHQ score is 5 and item 9 is negative, the ASQ is negative, and the CRAFFT is positive for occasional weekend alcohol use and intermittent cannabis use. What is the next best step in supporting this adolescent given the information provided by the screeners?

Complete the examination without any further counseling

Explore the extent of alcohol and cannabis use with the patient to understand reasons for and against use

Refer the patient to the emergency department for suicidal ideation with additional risk factors

Start the patient on a selective serotonin reuptake inhibitor (SSRI) for worsening depression

Ask the patient to complete an AUDIT screen to get further information given the results obtained

The correct answer is that you should explore the extent of alcohol and cannabis use with the patient to understand reasons for and against use.

In this case, the patient has evidence of depressive symptoms but is on the lower end of the PHQ-9 scale. Depressive symptoms should be explored further, as well as conducting a verbal screen for suicide, but referral to the emergency department or prescription of an SSRI based on this information would not be necessary and could be counter-therapeutic. Furthermore, the patient shows evidence of intermittent alcohol and cannabis use that needs to be further explored, both outside of and within the context of the depressive symptoms. Completing the examination without any further exploration of substance use or depressive symptoms would be inappropriate and could result in missing key information to support this patient. Although the AUDIT could be utilized to screen for substance use, the use of the CRAFFT is sufficient and screening again with the AUDIT is not warranted.

5. With the support of an MC3 Consulting Psychiatrist, which of the following agents can be helpful in addressing cravings for cannabis in youth struggling with a cannabis use disorder?

Atomoxetine

Bupropion

N-acetylcysteine

Carbamazepine

Topiramate

The correct answer is N-acetylcysteine.

The only agent identified above that has consistent evidence demonstrating benefit in addressing cravings for cannabis in youth, as well as potentially addressing cannabis use disorder, is N-acetylcysteine. All the other medications have little to no value for addressing cannabis cravings or cannabis use disorder, affirmed by a Cochrane Database Systematic Review in 2019.

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Clinical Pearls Video

Basics of Psychotropic Medication Use (Paresh Patel, M.D., Ph.D.)

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Alyssa Wealty |

Jan 26, 2024

Basics of Psychotropic Medication Use

Clinical Pearls Video Series

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

Assessment
- What are the factors related to the patient and their presentation I need to consider in terms of assessing the appropriateness of a medication? (0:07–2:35)
- What is the role of therapy, education, and other non-pharmacologic management when patients are on medications? (2:37–3:49)
Management
- What are some reasons I might want to start a psychotropic medication on a child or adolescent? (3:51–5:09)
- What are the things I should be considering as a primary care provider when I start a pediatric patient on a psychotropic medication? (5:10–5:58)
- What are some SSRIs to have in my tool box? Can you discuss the differences, transitioning between different SSRIs, dosing, time to effect, and managing side effects? (5:59–7:51)
- When should I think about using antipsychotics and what considerations should I have when prescribing them? (7:52–10:10)
Key Takeaways (10:11–11:08)

Presenter

Paresh Patel, M.D., Ph.D., Child & Adolescent Psychiatrist, University of Michigan

Synopsis

There are many treatment strategies for the management of mental health concerns in youth. These include:

Psychoeducation
Environmental adaptations
Changes to scheduling or routine
Psychotherapy and behavioral therapy
Family therapy
School and community-based interventions
Psychotropic medications

Successful medication use can help decrease symptoms and enable the youth, as well as their family, to better utilize non-pharmacologic resources. As primary care providers, you may often be asked to:

Prescribe medications
Titrate medications
Assess the potential for side effects of medications
Counsel families on medications
Taper off medications

Medications should be prescribed after careful diagnostic evaluation and consideration of the entire biopsychosocial framework of the child or adolescent’s presentation, as well as the predisposing, precipitating, and perpetuating factors contributing to psychopathology.

Psychiatric diagnoses in youth can vary over time. It is important to:

Re-evaluate periodically
Reflect on the diagnostic presentation over the evolving course
Be mindful that some youth demonstrate a chronic relapsing course that has varying contributors and requires flexibility in management strategies

Look for opportunities to reduce or discontinue medications when:

A child is doing well
The medication management does not match the underlying diagnostic conceptualization of their presentation

Remember to:

Reassess often and get collaterals to inform your understanding of the patient and their treatment
Always screen for trauma and stressors, as many psychiatric conditions in youth are triggered or perpetuated by them

In almost all cases, psychotherapy and medication together are more effective than medication alone.

Resources & Screening Tools

Resources Mentioned in the Video

MC3 Psychopharmacology Reference Cards: https://mc3michigan.org/pharma-cards

Screening Tools

Depression: Patient Health Questionnaire (PHQ-9): https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
Anxiety: Generalized Anxiety Disorder screener (GAD-7): https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf
Anxiety: Screen for Childhood-Related Disorders Scale (SCARED): https://www.aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/symptoms/ScaredChild.pdf
Suicidality: Ask Suicide Screening Questionnaire (ASQ): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf

Other Resources

MC3 Recordings:
Pediatric Meltdown Podcast Episodes:
- Psychopharmacology: Considerations Before Prescribing (Episode 132)
- Management of Youth Depression: Beyond Medications (Episode 149)
Breaking Down Mental Health Podcast Episodes:
- Aggression Management – Pharmacological Interventions
- Aggression Management – Nonpharmacological Interventions

References

Riddle M. Pediatric Psychopharmacology for Primary Care. 3rd ed. American Academy of Pediatrics; 2021.

Walkup J, Work group on quality issues. Practice parameter on the use of psychotropic medication in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2009;48(9):961-973. https://doi.org/10.1097/chi.0b013e3181ae0a08

Test your knowledge with an optional 8-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 75%.)

Basics of Psychotropic Medication Use Quiz

1. Psychiatric nosology was developed to prioritize diagnostic accuracy, i.e., the criteria are designed to confidently arrive at a definitive and stable diagnosis.

True

False

2. It is important to start a medication at the first encounter for a behavioral health problem because this demonstrates to the caregivers that you are taking their child’s mental health concerns seriously.

True

False

3. Structured questionnaires such as the PHQ-9 or GAD-7 are diagnostic tools with high predictive value when used to screen for mental illness in the general population.

True

False

4. All SSRIs are equally effective, so if a youth fails their first SSRI trial, one should next try a non-SSRI class medication.

True

False

5. Metabolic monitoring for a youth on an antipsychotic is only necessary for the 2nd generation (newer) antipsychotics like risperidone, olanzapine, aripiprazole, and quetiapine. The first generation antipsychotics, like haloperidol, fluphenazine, and chlorpromazine, do not increase the risk for metabolic syndrome.

True

False

6. One of the goals of psychotropic treatment in children is to help decrease symptoms and enable the youth and caregiving system to better utilize non-pharmacologic resources.

True

False

7. Common indications for psychotropic treatment in youth include (select all that apply):

To target a specific symptom, for example, insomnia, for which there is an empirically supported treatment

Patient and/or caregivers are actively engaged in non-pharmacologic treatment that has stalled due to persistent symptoms

The patient was expelled for disruptive behaviors and the school reports he cannot return until medicated

Externalizing behaviors are threatening placement and there is a safe and empirically supported treatment to temper the problem behaviors

Used to prevent the development of depression or anxiety in high-risk populations that may not exhibit symptoms of these disorders

8. Which of the following are appropriate indications for initiation of an antipsychotic? (Select all that apply.)

Tourette Syndrome

Disruptive behaviors unresponsive to time-outs and loss of privileges

Marked irritability in a youth with Autism Spectrum Disorder

Bipolar I manic episode

To augment a partial response to an antidepressant for a Major Depressive Disorder

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Clinical Pearls Video

Suicidal and Non-Suicidal Self-Harm (Alejandra Arango, Ph.D.)

No Comments |

Alyssa Wealty |

Jan 25, 2024

Suicidal and Non-Suicidal Self-Injurious Behavior

Clinical Pearls Video Series

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

Assessment
- Is it important to assess for suicide risk in patients presenting to primary care practice? (0:08–2:55)
- What do I do if there is a positive screen given I am in a busy practice? (2:56–5:02)
- How do I talk to families about suicide, firearms, other lethal means, their restriction, and suicide risk? (5:03–6:29)
Management
- How do I know if it is safe to send a child home who has suicidal ideation or self-injury? (6:30–8:17)
- How do I treat a patient presenting with suicidal risk? What are the evidence-based therapies and what is the role of medication? (8:18–13:40)
- What do I do if I cannot get access to timely mental health services for my patient who is at-risk for suicide? (13:41–14:52)
Key Takeaways (14:53–16:17)

Presenter

Alejandra Arango, Ph.D., Child Psychologist, University of Michigan

Synopsis

Suicide is a preventable public health tragedy and the leading cause of death among youth ages 10-24 in the United States.

A notable proportion of youth experience suicidal thinking or have a history of engagement in suicidal and/or non-suicidal self-injurious (NSSI) behaviors.

Approximately 22% of US high school students report that they seriously considered making a suicide attempt, while 10% report having made a suicide attempt in the past year (CDC, 2023).
The past year prevalence of NSSI is also estimated to be high among adolescents (~23% in a non-clinical sample).

Suicide risk notably increases in the transition into adolescence. There is evidence for an increase in suicide risk among subgroups of adolescents (e.g., biological females, Black and Hispanic youth).

Additionally, sexual and gender minority youth report elevated suicidal ideation and behaviors and are at particularly high risk for suicide.
Suicide risk and protective factors span demographic characteristics (e.g., biological sex, gender, age, race/ethnicity), psychopathology (e.g., depression), interpersonal stressors (e.g., peer victimization, social connectedness), as well as a history of self-harm thinking and behaviors.

NSSI includes self-harm behaviors (e.g., cutting, burning) without suicidal intent. Functions of NSSI are varied and may include communication of distress, escape from a situation or emotions, a desire to feel in control, wanting to reduce feelings of numbness, self-punishment, and intent should always be clarified.

Emergency department (ED) visits due to suicide attempts and other suicidal behavior have been climbing in the past few years, especially among girls.

Notably, ED visits due to self-harm behaviors have notably increased in recent years.
Among youth, under 19, who died by suicide, approximately 38% and 77% had contact with the healthcare system in the month and year prior to their death, respectively.

Primary care settings present a unique and critical opportunity to identify and intervene with youth at risk for suicide or who are engaging in NSSI.

Resources & Screening Tools

Resources Mentioned in the Video

American Academy of Pediatrics, Blueprint for Youth Suicide Prevention: https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/
Zero Suicide: https://zerosuicide.edc.org/
Safety planning: Stanley-Brown Safety Plan https://sprc.org/online-library/stanley-brown-safety-plan/
Counseling Access to Lethal Means (CALM) training course: https://zerosuicide.edc.org/resources/trainings-courses/CALM-course
988 Suicide and Crisis Hotline: https://988lifeline.org/current-events/the-lifeline-and-988/

Screening Tools

Depression: Patient Health Questionnaire (PHQ-9): https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
Suicidality: Ask Suicide Screening Questionnaire (ASQ): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf
Suicidality: Ask Suicide Screening Questions Brief Suicide Safety Assessment (ASQ BSSA): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/youth-outpatient/bssa_worksheet_outpatient_youth_asq_nimh_toolkit.pdf
Suicidality: Columbia Suicide Severity Rating Scale (CSSR-S): https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf
Nonsuicidal self injury and suicidality: Suicidal ideation; Onset, frequency, and methods; Aftercare; Reasons; and Stage of change (SOARS): https://www.contemporarypediatrics.com/view/soars-model-risk-assessment-nonsuicidal-self-injury

Other Resources

MC3 Recordings:
Pediatric Meltdown Podcast Episodes:
Breaking Down Mental Health Podcast Episodes:
- What is Suicidal Ideation? Self Injurious Behavior? (Episode 4)
- Safety Assessment and Planning (Episode 5)

References

Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29(6) 870-877. https://doi.org/10.1007/s11606-014-2767-3

Centers for Disease Control and Prevention. WISQARS. 10 Leading Causes of Death, United States, 2018-2020. https://wisqars.cdc.gov/data/lcd/home

Centers for Disease Control Prevention. (2023). Youth Risk Behavior Survey Data Summary & Trends , 2011–2021. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf

Cha CB, Franz PJ, Guzmán EM, Glenn CR, Kleiman EM, Nock MK. Annual Research Review: Suicide among youth–epidemiology, (potential) etiology, and treatment. J Child Psychol Psychiatry. 2018;59(4):460-482. https://doi.org/10.1111/jcpp.12831

Gaylor EM, Krause KH, Welder LE, Cooper AC, Ashley C, Mack KA, et al. Suicidal thoughts and behaviors among high school students—Youth Risk Behavior Survey, United States, 2021. MMWR supplements. 2023;72(1):45. https://doi.org/10.15585/mmwr.su7201a6

Haas AP, Eliason M, Mays VM, Mathy RM, Cochran SD, D’Augelli AR, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex. 2011;58(1):10-51. https://doi.org/10.1080/00918369.2011.534038

Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70(3):300-310. https://doi.org/10.1001/2013.jamapsychiatry.55

Office of the Surgeon General. (2021). Protecting Youth Mental Health: The US Surgeon General’s Advisory [Internet]. surgeon-general-youth-mental-health-advisory.pdf (hhs.gov)

Ward D. Office Practicum, Pediatric Success Series: The Concerning Trend in Behavioral Health Emergency Room Visits for Children and Adolescents. https://www.officepracticum.com/blog/the-concerning-trend-in-mental-health-emergency-room-visits-for-children-and-adolescents/

Yard E, Radhakrishnan L, Ballesteros MF, Sheppard M, Gates A, Stein Z, et al. Emergency Department visits for suspected suicide attempts among persons aged 12-25 years before and during the COVID-19 pandemic- United States, January 2019-May 2021. Morbidity and Mortality Weekly Report, 70(24), 888. https://www.cdc.gov/mmwr/volumes/72/wr/mm7226a2.htm?s_cid=mm7226a2_w

Test your knowledge with the optional 5-question multiple choice quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)

Suicidal and Non-Suicidal Self-Injurious Behavior Quiz

1. Which of the following is most accurate about suicide risk screening in pediatric primary care practices? (Select one.)

Only screen adolescents who present with depressive symptoms

Be cautious with screening since asking about suicide actually increases suicide risk

There are several brief, validated screening tools that can be integrated into ambulatory care

Screening should be reserved for youth ages 14 and older given limited risk in younger populations

Screening should be conducted with the caregiver in the room to model how to review suicide risk for the family

The correct answer is that there are several brief, validated screening tools that can be integrated into ambulatory care.

Though it is good practice to screen youth presenting with depression, not all youth at risk for suicide experience depressive symptoms and routine screening is recommended for youth 12 and older (as suicide risk notably increases in the transition into adolescence) with some practices screening at even younger ages. Research has shown that asking about suicide does not increase suicide risk. Rather screening for suicide provides an opportunity to engage in suicide prevention. There are several validated brief screening tools (e.g., Ask Suicide Screening Questions (ASQ) that can feasibly be implemented in busy primary care settings. Often, screening is more effective if the adolescent is able to respond confidentially.

2. You are conducting a well child visit with an adolescent and notice a Patient Health Questionnaire (PHQ-9) score of 18 with a positive response to question 9 on the PHQ-9. Which of the following is the next best course of action in the care of this patient? (Select one.)

Referring the patient to the Emergency Department for a comprehensive psychiatric evaluation is required since the patient is expressing suicidal thinking

Ask the child to complete the PHQ-9 again to confirm that the original response was not impacted by poor understanding of the PHQ-9

Start the patient on an SSRI given the severity of their presenting depression and the need for more urgent treatment

Speak to the patient privately to review the responses to the PHQ-9 to further assess suicide risk

Ask that the family schedule a mental health visit within the next 2 weeks to ensure that the patient receives timely mental healthcare

The correct answer is that you should speak to the patient privately to review the responses to the PHQ-9 to further assess suicide risk.

Suicide risk and self-harm behaviors can often be managed in the outpatient setting, without higher-level of care (i.e., emergency department evaluation, psychiatric hospitalization). Oftentimes, it is not in the best interest of the youth to be sent directly to ED upon a positive screen. If not indicated, referral to a higher level of care can have iatrogenic effects. A referral to specialized behavioral health services is often appropriate, but should not obviate the need for further assessment, particularly to determine the acuity and severity of the patient’s suicidal thoughts. Further assessment, conducted confidentially with the adolescent, can aid with further assessment of suicide risk and should be the next step in the care of this patient.

3. Which of the following is most accurate about talking to caregivers after a teen discloses non-suicidal self-harm (NSSI)? (Select one.)

It is critical to involve caregivers of teens who are self-harming once this has been identified

Providers should not break confidentiality and share information with caregivers, unless the teen needs to go to the hospital

Caregivers often express strong emotions that can be distressing to the teen, so the teen should be encouraged to discuss with the caregivers when they are ready

The provider should draft a safety contract related to the self injurious behavior and ask the teen and caregiver to sign it

The correct answer is that it is critical to involve caregivers of teens who are self-harming once this has been identified.

It is often important to involve caregivers as they may be able to provide the youth with support and frequently help to secure additional care (e.g., outpatient mental health services). Providers should weigh the risks and benefits of breaking confidentiality, however, to ensure youth safety, breaking confidentiality may be warranted. Though, caregivers may have emotional reactions when learning that their child is engaging in NSSI, sharing this information ensures an opportunity to provide guidance to caregivers, discuss misconceptions, and create a plan to support the youth.

4. Which of the following has no evidence of benefit in managing suicide risk in youth? (Select one.)

Collaborative safety planning

No-suicide contract

Discussing safe storage of lethal means

Caregiver education

Coping skills to manage emotional distress

The correct answer is that no-suicide contracts have no evidence of benefit in managing suicide risk in youth.

Collaborative safety planning, discussions of how to make a home suicide safe, and collaborating with caregivers regarding how to support their youth are all recommended practices for working with youth at elevated suicide risk. Furthermore, supporting youth with how to manage strong emotions and distressing situations more adaptively with coping skills can be helpful in mitigating progression of strong emotions to suicidal ideation and suicidal behaviors. No-suicide contracts are not recommended as they do not provide the individual with coping skills that can be used in the face of suicidal urges. There is no evidence that these contracts provide any benefit to the patient and may be harmful in that they give the patient and family a false sense of security and detract from other evidence-based interventions that can be of greater support to the patient and family.

5. Which of the following are important components of the safety planning intervention? (Select three of the options below.)

Identification of warning signs or triggers for suicidal thinking or self-harm urges

A root cause analysis of what stressors are contributing to the suicidal thoughts

Description of previous psychotherapy and medication trials

Emergency contact information (e.g., 988, number to local emergency department)

A record of past depression and suicide screening scores to track risk over time

Specific steps for making the home environment suicide safe

Reasons that the patient does not want to continue to live

Signature of the patient and a caregiver

The correct answers are that important components of the safety planning intervention include:

Identification of warning signs or triggers for suicidal thinking or self-harm urges
Emergency contact information (e.g., 988, number to local emergency department)
Specific steps for making the home environment suicide safe

The following are key components of safety planning: identification of triggers or warning signs, internal coping skills, available social supports, emergency resources, lethal means safety, and reasons for living. The other items may be part of general clinical assessment or history gathering, but are not parts of a safety planning intervention. Signature of the patient and caregiver is not required, as long as the plan is developed collaboratively and reviewed with the patient and caregiver.

The correct answers are that important components of the safety planning intervention include:

Identification of warning signs or triggers for suicidal thinking or self-harm urges
Emergency contact information (e.g., 988, number to local emergency department)
Specific steps for making the home environment suicide safe

The correct answers are that important components of the safety planning intervention include:

Identification of warning signs or triggers for suicidal thinking or self-harm urges
Emergency contact information (e.g., 988, number to local emergency department)
Specific steps for making the home environment suicide safe

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