APNA Position: Youth Suicide Prevention

Introduction

Suicide in the United States is a public health crisis with continuously rising suicide rates since 2007 and an all-time high reported in 2022 (CDC, 2023; Curtin et al., 2023). An annual estimate of $510 billion dollars in U.S. economic burden is associated with suicide and ED-treated nonfatal self-harm injuries, with $484 billion attributed to life lost years, $13 billion associated with medical spending, $10 billion associated with injury morbidity, and $3 billion in nonfatal injury work loss (Peterson et al., 2024). The prevalence of suicidal ideation (SI), suicide plans, and suicide attempts among youth has increased over the last decade (CDC, 2023). Suicide is the second leading cause of death for children ages 10-14 and the third leading cause of death for adolescents ages 15-19 (Curtin et al, 2023).

It is the position of the American Psychiatric Nurses Association (APNA) that psychiatric-mental health (PMH) nurses at all levels of practice can reduce suicide mortality by intervening with children, adolescents, and families across levels of care through youth-relevant suicide screening, risk assessment, and treatment planning. These are essential responsibilities within the scope and standards of practice of psychiatric-mental health nurses (ANA, APNA, ISPN, 2022). The Joint Commission (TJC) has established National Patient Safety Goal (NPSG) 15.01.01 to improve the quality and safety of care for individuals being treated for behavioral health conditions and those identified as high risk for suicide within all Joint Commission-accredited hospitals, including critical access hospitals and behavioral health care organizations. To meet this goal, TJC requires: environmental risk assessments, validated screening and evidence-based assessments, documentation of patient’s risk and mitigation plans, counseling and follow-up care at discharge, policies and procedures addressing care of at-risk patients and evidence that these policies and procedures are being followed, monitoring policies and procedures implementation and effectiveness, and taking action to improve compliance (TJC, 2019; TJC, 2023).

In 2015, the APNA Board of Directors endorsed nine essential competencies to assess and manage hospitalized patients admitted to psychiatric settings (APNA, 2015). At the time of development, population-based measures specific to youth were not addressed. Using evidence-based resources, this position paper addresses youth suicide succinctly and holistically within the context of the PMH nurses’ role and provides PMH nursing recommendations relevant to reducing youth suicide mortality.

APNA takes the position that psychiatric-mental health nurses at all levels of practice can reduce suicide mortality by intervening with children, adolescents, and families across levels of care through youth-relevant suicide screening, risk assessment, and treatment planning.

Discussion

Despite decades of research, many barriers exist to accessing pediatric mental health care and suicide continues to be a leading cause of death among youth. Several youth-relevant considerations warrant the attention of PMH nurses to aid in early identification of suicide risk, high quality care delivery, and effective prevention strategies. These considerations have been identified through a review of the literature and are summarized below. Importantly, these considerations are listed in alphabetical order and may not be mutually exclusive. Youth experiencing multiple risk factors should be prioritized for suicide risk screening and prevention.

Access to Lethal Means: Limiting youth access to lethal means is fundamental to suicide prevention efforts. Lethal means can include firearms, medications, poisons, and sharp objects. Firearm suicide totals about 40% of all suicides among youth ages 10-14 and 55% of all suicides among individuals ages 15-24 (Center for Disease Control and Prevention, 2021). Most firearm related suicides take place in or around the home.

Bullying: There is a strong association between bullying among youth, whether the victim or perpetrator, and suicidal ideation and behaviors (Holt et al., 2015). Being a victim of bullying is a significant predictor for suicide attempts in children, adolescents, and young adults (Ong et al., 2021). Both bullying and cyberbullying have been linked to suicidal ideation and suicidal behaviors (Patchin & Hinduja, 2019; Alavi et al., 2015). Perpetrators of cyberbullying are also at increased suicide risk, particularly those with concurrent psychologic distress or psychiatric disorders (John et al., 2018; Kwan et al., 2020). Youth who report a history of both current suicidal ideation and a suicide attempt in the past year reported higher levels of both victimization and perpetration of bullying compared to those with no history of a suicide attempt (Vergara et al., 2019).

Child and Adolescent PMH Care: Most emergency departments (ED) do not have child and adolescent psychiatric specialists to triage, assess, and coordinate care for this population (Cree et al., 2021). The rising demand for child and adolescent PMH services has far outweighed the supply of pediatric PMH professionals. As a result, many organizations struggle to find beds for youth presenting with PMH concerns and utilize ED or medical unit boarding. Many concerns related to safety and trauma-informed care arise from ED and medical unit boarding of PMH patients. Access to all levels of care continues to be a concern for this population.

Contagion: Suicide contagion is an increase in suicide and/or suicidal behaviors related to exposure to suicide or suicidal behaviors. Direct and indirect exposure to suicidal behavior has been shown to precede an increase in suicidal behavior in persons at risk for suicide, especially in adolescents and young adults (Walling, 2021). Approximately 1 in 5 teens have been exposed to suicide by a friend, acquaintance, or family member (Andriessen et al, 2015). Postvention processes are needed for those affected by suicide, especially at-risk youth, to facilitate a healthy grieving process, minimize additional trauma, and alleviate the risk of contagion.

Experienced Houselessness: Youth who experience houselessness have three times greater likelihood of attempting suicide compared to their stably housed peers (Smith-Grant et al., 2022). Further, they are at increased risk for being victim to violence, substance use, survival sex, and mental distress. Importantly, youth experiencing houselessness and having had a prior 90-day health care encounter for any reason outside of mental health concerns had significantly decreased suicide risk (Sakai-Bizmark et al., 2022).

Juvenile Justice System: Suicide is more common among youth in the juvenile justice system than in the general population (Stokes et al., 2015). Suicide rates are estimated at 21.9 per 100,000 youth in juvenile justice facilities (Gallagher & Dobrin, 2006) compared with approximately 7 per 100,000 adolescents ages 15 to 19 years in the general population.

Minoritized Youth: Subpopulations of youth who experience pronounced suicide disparities include those who are marginalized or minoritized. Having a minoritized identity does not inherently make an individual suicidal, but rather, the experiences associated with marginalization (e.g., stigma, discrimination, rejection, victimization, and other adversities) increase the risk for psychological distress and poor mental health outcomes such as suicide. Examples of minoritized subpopulations of youth include:

• Gender Identity: Transgender and gender-diverse youth have significantly higher rates of suicide outcomes, even when compared to their heterosexual and sexual minority peers (Price-Feeney et al., 2020). Suicide in this population is often associated with family rejection, discriminatory school environments, and public policy (Anderson & Ford, 2022; Kaczkowski et al., 2022). However, youths’ chosen names being used in more environments, for example by healthcare workers, is associated with a significantly decreased risk for suicide (Russell et al., 2018).
• Racial and Ethnic Identities: From 2007-2021, the number of Black teens reporting a suicide attempt nearly doubled from 13.2% to 21.6% (CDC, 2023). In recent years, suicide death rates have disproportionally risen among Black youth, especially preteen children. Between 2001-2015, Black youth ages 5-12 were twice as likely to die by suicide compared to white youth in the same age range (Bridge et al. 2018). Additionally, there is a significant increase in the number of Black girls who died by suicide (Sheftall et al., 2022). Among American Indian/Alaska Native youth ages 15-19, suicide is the leading cause of death and the second for those ages 10-14 (Benton, 2022). Among Asian American, Pacific Islander, and Native Hawaiian youth 15-19 years of age, suicide is also the leading cause of death and the third for those ages 10-14. Among Hispanic youth 10-14 years of age, suicide deaths increased by 89% among boys and 79% among girls between 2015 and 2019. Additionally, research demonstrates that multiracial youth, one of the fastest growing populations of youth in the U.S., have significantly higher rates of suicidal ideation, suicide plans, and attempts when compared to their white peers (Benton, 2022).
• Sexual identity: Youth who identify as lesbian, gay, or bisexual experience significantly higher rates of suicidal ideation, suicide plans, and attempts than their heterosexual peers (Ivey-Stephenson et al., 2020).

Rurality: Rural youth have a greater incidence of suicide than urban youth, a geographic disparity that has increased over time (Fontanella et al., 2015). From 2010 to 2018, the incidence of suicide among youth ages 10-19 increased 1.5 times faster in rural areas compared with urban areas (CDC, 2020). Low health care practitioner density is associated with higher suicide rates and youth in rural counties have access to fewer mental health services than those in urban and suburban counties (Cummings et al., 2016).

Social Media: Social media use is ubiquitous among youth, with 8-12-year-olds averaging about 5.5 hours of screen media per day and 13-18-year-olds averaging about 8.5 hours of screen media per day (Rideout et al., 2022). Negative upward social comparison and cyber victimization have been associated with depression, anxiety, and suicidal ideation in adolescents (Bannink et al., 2014; Nesi & Prinstein, 2015). However, the use of social media is complex, as teens who are at risk for or experiencing mental health challenges may be more vulnerable to the negative effects of social media while those same teens are also likely to benefit from the resources and community support that social media facilitates (Nesi, Mann, and Robb, 2023).

Substance Use: Substance use significantly increases the risk of suicidal ideation among youth, positioning it as the second most prevalent precursor to suicide, following depression. Youth substance use also has a strong correlation with co-morbid mental health disorders (Latif et al., 2022). The surge in suicide rates among youth closely aligns with the escalating prevalence of youth substance use disorders (SUD) (Baiden et al., 2023; Mars B. et al., 2019). Adolescents with SUD are 4 times more likely to contemplate suicide, formulate a plan, or attempt suicide compared to peers without SUD (Jones, et al., 2023). Further, with each additional substance used, the risk of suicide attempts escalates by 1.241 times among youth (Guvendeger Doksat N. et al., 2017).

Trauma: Childhood trauma is associated with an elevated risk of suicidal ideation and suicide attempts (Rogerson et al., 2023), particularly with compounded trauma exposure or involvement of sexual and emotional abuse (Bach et al., 2018; Wu et al., 2022; Miche et al., 2019; Asarnow et al., 2020). There is a significant association between past trauma and adolescents presenting to the emergency department for suicidal crises (Ashworth et al., 2023). Childhood maltreatment is also associated with 2-4 times increased risk of suicidal behavior (Zelazny et al, 2019).

Conclusions and Recommendations

APNA takes the position that psychiatric-mental health (PMH) nurses at all levels of practice can reduce suicide mortality by intervening with children, adolescents, and families across levels of care through youth-relevant suicide screening, risk assessment, and treatment planning. Youth and their caregivers need preventative education and increased access to care at all levels. PMH nurses are well-positioned as direct care providers to youth, and often the most trusted professionals, to screen and thoroughly assess suicide risk using evidence-based practice and a trauma-informed approach. Based on the presented discussion, the following recommendations are meant to serve as a readily accessible resource to nurses caring for pediatric patients and to enhance PMH nursing practice toward youth suicide prevention.

• Assessment and Screening: To facilitate early suicide identification and intervention, PMH-RNs should continue to follow PMH assessment practice standards (ANA, APNA, ISPN, 2022, pg. 59-60) in settings where youth present with mental health concerns to perform: 1) comprehensive mental health assessments and 2) evidence-based suicide screenings with the inclusion of youth-relevant, biopsychosocial factors identified in the discussion (i.e., access to lethal means, bullying, houselessness, identity, rurality, SUD, trauma, etc.). TJC mandates using validated tools to assess for SI for patients ages 12 years and up (TJC, 2020). The Ask Suicide-Screening Questions (ASQ) is a brief and validated measure to screen for suicide among patients in all health settings (Aguinaldo et al., 2021). The Columbia Suicide Severity Scale can offer both screening and assessment of suicidal behavior/ideation and is validated in youth ages 6 and older (Posner et al., 2011; TJC, 2020). Appropriate follow-up after validated screening may depend on the health care setting and can range from referrals and recommendations for the youth and family to further assessment and treatment planning (NIMH, n.d.).
• Inpatient care and beyond: Organizations should have established policies for boarding patients to ensure their needs are met and appropriate treatment and/or transfer to suitable care. Additionally, the concern with boarding PMH pediatric patients highlights systemic issues within the current mental health care infrastructure and the urgency to focus on primary prevention and access to outpatient and community PMH care across the lifespan.
• PMH Scope of Practice: The most recent APNA Workforce Report found the majority of PMH-RNs (62.4%) work in hospitals, while 14.4% work in outpatient settings. The paucity of PMH-RNs in community settings was described as a “missed opportunity” (Gerolamo et al., 2022). It is imperative to maximize PMH nursing scope of practice regarding suicide screening, assessment, and treatment at all levels (whether inpatient RN, outpatient RN, school RN, community health RN, APRN, or nurse researcher).
• Prevention: Primary prevention is key and lies in the community. If appropriately addressed in community settings, inpatient hospitalizations (and emergency department boardings) may be reduced. The National Strategy for Suicide Prevention lists community-based suicide prevention as the first strategic direction (SAMHSA, 2024). The American Academy of Pediatrics Blueprint for Youth Suicide Prevention also emphasizes the importance of community-based prevention and partnerships between clinicians, schools, and the community (AAP, 2022). Increasing suicide screening and prevention efforts within the community is vital, whether that includes moving PMH nurses to community settings, training others in the community, or highlighting organizations that provide advocacy, education, support, and public awareness. Examples include the 988 Suicide and Crisis Lifeline, the National Alliance on Mental Illness, the American Foundation for Suicide Prevention, etc.
• Safe Homes: Children and adolescents exist within families. Most preteen deaths by suicide occur in the home (Sheftall et al., 2016). PMH nurses at all levels can decrease stigma and improve suicide literacy (Burke et al., 2023) by engaging in family education that includes suicide risk factors, warning signs, limiting access to lethal means, healthy social media use, and social determinants of health. PMH nurses can teach parents when and how to talk to their children about suicide risk and educate parents about next steps if youth endorse suicidal thoughts or behaviors. PMH nurses are encouraged to familiarize themselves with local and national crisis resources and share these resources with families.
• Competencies and Education: The current APNA competencies and trainings on suicide focus on inpatient staff nurses for adult care (APNA, 2015; Puntil et al., 2013). It is recommended that, in addition to completing the existing competencies, nurses should pursue education that emphasizes youth-relevant considerations for suicide. Such education could include thorough suicide screening and assessment both in and beyond the hospital setting (e.g., outpatient psychiatry, primary care clinics, school based, telehealth, etc.), assessment of social determinants of health and environmental contexts youth are exposed to, and youth-specific discharge planning needs (e.g., safety planning, addressing transition back to school following an inpatient stay, returning to outpatient care, etc.). Additionally, APNA is currently developing an add-on module specific to youth suicide that should be leveraged for increasing knowledge and understanding.
• Dissemination of Evidence-Based Research: It is imperative that PMH nurse researchers focus on the problem of youth suicide and disseminate these findings through publications and presentations. Nursing journals should consider publishing special issues in youth suicide prevention to disseminate evidence-based research findings and interventions to nurses at all levels of practice.

View the APNA Youth Suicide Prevention Workgroup

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Approved by the APNA Board of Directors October 8, 2024.

Youth Suicide Prevention Workgroup

Chair

Jamie Zelazny, PhD, MPH, RN

Steering Committee

Avery Anderson, PhD, PMHNP-BC, APRN
Isabel Buckingham, BSN, RN
Jessica Gordon, PhD, APRN, CPNP-PC, PMHNP-BC
Wanda Hilliard, DNP, MBA, APRN, PMHNP-BC
Michaela Hogan, DNP, APRN, PMHNP-BC, CNE
Vonda Keels-Lowe, MSN, CPN, PMHNP-BC, APRN
Andrea Kwasky, NP, DNP, PMHCNS-BC, PMHNP-BC
Jaime Lovelace, MSN, PMH-BC
Judy Odili, MS, RN, CNL
Brigette Vaughan, MSN, APRN-BC, NP
Daniel Wesemann, NP, MSW, RN, APRN, PMHNP-BC, FAANP

Advisory Panel

John Brewer DNP, PMHNP
Roshanda Bridgraj RN, BSN, PMH-BC, CARN
Tamia Chapple MSN, MBA, HCM, APRN, PMHNP-BC, GERO-BC
Brittany Daniel MSN
Marion Donohoe DNP, APRN CPNP_PC
Kathleen Dvorsak MSN, RN
Feruza  Esanova MPA, BSN, RN, NE-BC, CSSM, CNOR
Holly Gray DNP, APRN, PMHNP-BC
Jacqueline Insana RN, MSN
Judith Jarosinski PhD, RN
Kristen Kichefski DNP, MBA, RN, PMH-BC, NEA-BC
Janie LeVieux PhD, LPC-S, RN-BC, NHDP-BC
Pamela Lusk, DNP, RN, PMHNP-BC, FAANP, FNAP, FA
Georgianna Marks PhD, APRN
Regina Owen DNP, PMHNP-BC
Barbara Peterson PhD, RN, PMHCNS, FNAP
Kristin Rattray BSN, RN, PMH-BC
Robin Schafer DNP, CPNP, PMHNP-BC
Valerie Seney PhD, MA, LMHC, PMHNP-BC
Teresa Setnar MSN, RN
Marci Zsamboky DNP, PMHNP-BC, PMHCNS-BC, CNE