Pediatric emergency medicine trisk 1046

child. (What did the child think or hope would happen? Did the child take all
the pills that were available? Did he or she expect to wake up? Did he or she
tell anyone after taking the pills? Did he or she leave a suicide note? Now
that he or she is awake, is the child pleased or displeased to be alive? Does
he or she intend to try again?)
Children who threaten suicide without making an actual attempt should
also be questioned carefully about suicidal intent. (How long has the child
considered suicide? What methods? When will this take place? Previous
attempts? How about other family members?) Psychotic and depressed
children, especially when the parents appear unable to supervise the child,
should elicit particular concern.
Assessment of the child’s level of impulsivity is also important ( Table
126.16 ). Does the attempt appear to have been impulsive rather than
planned? Is there a history of prior impulsive behaviors? Is there evidence of
impulsivity during the ED interview?
TABLE 126.14
CHILD AND ADOLESCENT SUICIDE: ASSESSING MEDICAL
LETHALITY
Vital signs
Level of consciousness
Evidence of drug/alcohol intoxication (e.g., pupils, smell on breath)
Need for emesis, lavage, or catharsis
Acute medical complications (cardiac, respiratory, renal, neurologic)
Indications for medical hospitalization, including intensive care
Residual abnormalities


TABLE 126.15
CHILDHOOD AND ADOLESCENT SUICIDE: ASSESSING
SUICIDE INTENT
Circumstances of suicide attempt

Nature of suicide attempt (e.g., ingestion vs. violent means)
Use of multiple methods
Method used to extreme (all vs. some pills ingested)
Suicide note written
Secrecy of attempt (attempt concealed vs. revealed)
Premeditation (long planned vs. impulsive attempt)
History of prior attempts
Child self-report
Premeditation of attempt
Anticipation of death
Desire for death
Attempt to conceal attempt
Nature of precipitating stresses
Child’s mental status
Orientation/cognitive intactness
Presence/absence of psychosis
Manner of relating to physician
Current suicidality
Response to being saved/being unsuccessful in attempt
Active plan for another attempt
Readiness to discuss stresses
Readiness to accept external and family support
Nature of orientation toward future
The physician should ask the child and family about possible precipitating
events to determine what changes in the environment may be needed. The
strengths of the family should be assessed to determine whether sufficient
social support exists to allow for outpatient management ( Table 126.17 ).


The ACEP online suicide assessment and treatment tool can be accessed

at .
Management
Evaluation for Hospitalization. No universally agreed-on criteria have been
established for when to hospitalize a child with suicidal behavior and when
they can be safely managed on an outpatient basis. Garfinkel and Golombek
identified seven areas to assess to determine whether hospitalization is
indicated ( Table 126.18 ).
The degree to which the family can commit to support the child’s safety
and well-being and other resources (extended family, neighbors, peers, and
teachers) must be assessed. The decision to hospitalize the child is made
when the child’s safety is still in doubt after these questions have been
answered.
TABLE 126.16
CHILDHOOD AND ADOLESCENT SUICIDE: ASSESSING
IMPULSIVITY
Evidence of impulsive suicide attempt
History of prior impulsive behaviors
Evidence of impulsivity during interview


TABLE 126.17
CHILDHOOD AND ADOLESCENT SUICIDE: ASSESSING
STRENGTHS AND SUPPORTS
Strengths and assets of child
Ability to relate to physician
Ability to rely on parents in crisis
Ability to acknowledge problem
Positive orientation toward future
Strengths and assets of family
Commitment to child

Ability to unite during crisis
Problem-solving abilities
Capacity to supervise child (support and limits)
Ability to use external supports
Nature of external supports
Outpatient psychiatrist/family physician
Extended family
Neighbors/other significant adults
Religious community
Self-help groups
Any suicide attempt deserves a thorough assessment by the emergency
physician and a complete psychiatric consultation. Hospitalization should be
used in the circumstances listed in Table 126.19 .
Initiating Treatment. If inpatient treatment is required, the child and family
should be informed about the goals of hospitalization and the active role of
the family in the treatment emphasized. Instances in which the child or
parents do not agree to hospitalization, involuntary commitment may be
needed as a last resort.
Outpatient management of suicidal behavior becomes feasible when (i)
the child and family are cooperative and engageable; (ii) the attempt is
determined not to have been too serious in terms of intent/medical lethality;