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)
Nasuh Malas, M.D., M.P.H., Child & Adolescent Psychiatrist, University of Michigan
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 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:
- Pediatric Meltdown Podcast Episodes:
- Breaking Down Mental Health Podcast Episodes:
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%.)
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)
Alyse Folino Ley, D.O., Child & Adolescent Psychiatrist, Michigan State UniversityTraumatic 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 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:
- Pediatric Meltdown Podcast Episodes:
- Breaking Down Mental Health Podcast Episode:
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%.)
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)
Joanna Quigley, M.D., Child & Adolescent Psychiatrist, University of Michigan
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 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:
- Pediatric Meltdown Podcast Episode:
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%.)
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)
Paresh Patel, M.D., Ph.D., Child & Adolescent Psychiatrist, University of Michigan
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 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 Psychopharmacology: Managing Depression and Anxiety, by Richard Dopp, M.D.
- Pediatric Psychopharmacology: Managing Disruptive Behavior, by Paresh Patel, M.D., Ph.D.
- Pediatric Anxiety Disorders: Prevalence and Management, by Kate Fitzgerald, M.D.
- Treating Complex Depression in Youth, MC3 ECHO: Behavioral Health, by Richard Dopp, M.D.
- Pediatric Meltdown Podcast Episodes:
- Breaking Down Mental Health Podcast Episodes:
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%.)
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)
Alejandra Arango, Ph.D., Child Psychologist, University of MichiganSuicide 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 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:
- Screening Youth For Suicide Risk: Can it be done in a busy pediatric practice? (Episode 8)
- Self-Injurious Behaviours in Youth: Assessment and Management (Episode 144)
- Preventing Youth Suicide: Risk Assessment and Management (Episode 158)
- Youth Suicide Prevention: Safety Planning and Lethal Means Safety Counseling (Episode 159)
- Breaking Down Mental Health Podcast Episodes:
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
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