Teen Suicide Risk A Practitioner Guide to Screening,

Assessment, and Management

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T een Suicide Risk
 The Guilford Child and Adolescent Practitioner Series
Editors: John Piacentini, PhD, and John T. Walkup, MD

This series offers effective, innovative intervention strategies for today’s

child and adolescent practitioners. Focusing on persistent clinical chal-
lenges that cut across diagnoses and often come up in practice, books in the
series ­present evidence-based tools for conceptualizing and addressing cli-
ents’ i­ndividualized needs. These concise volumes provide what is missing
from many evaluation and treatment manuals: the nuts-and-bolts techniques
required for everyday clinical work. Each accessible guidebook includes a
treasure trove of suggested interventions, complete with case examples,
practical tips, sample dialogues, and practitioner-friendly resources, such as
reproducible handouts and forms.
 Teen
Suicide
Risk
A Practitioner Guide to Screening,
Assessment, and Management

Cheryl A. King
Cynthia Ewell Foster
Kelly M. Rogalski

THE GUILFORD PRESS

New York  London
© 2013 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
Except as indicated, no part of this book may be reproduced, translated, stored in a
retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, microfilming, recording, or otherwise, without written permission from
the publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED PHOTOCOPY LICENSE

These materials are intended for use only by qualified professionals.
The publisher grants to individual purchasers of this book nonassignable permission to
reproduce all materials for which photocopying permission is specifically granted in a
footnote. This license is limited to you, the individual purchaser, for personal use or use
with individual clients. This license does not grant the right to reproduce these materi-
als for resale, redistribution, electronic display, or any other purposes (including but
not limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites,
Internet or intranet sites, and handouts or slides for lectures, workshops, webinars, or
therapy groups, whether or not a fee is charged). Permission to reproduce these materi-
als for these and any other purposes must be obtained in writing from the Permissions
Department of Guilford Publications.

The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice that
are accepted at the time of publication. However, in view of the possibility of human
error or changes in behavioral, mental health, or medical sciences, neither the authors,
nor the editor and publisher, nor any other party who has been involved in the prepara-
tion or publication of this work warrants that the information contained herein is in every
respect accurate or complete, and they are not responsible for any errors or omissions or
the results obtained from the use of such information. Readers are encouraged to confirm
the information contained in this book with other sources.
Library of Congress Cataloging-in-Publication Data
King, Cheryl A. Polewach, 1955–
Teen suicide risk : a practitioner guide to screening, assessment, and management /
by Cheryl A. King, Cynthia Ewell Foster, and Kelly M. Rogalski.
pages cm. — (The Guilford child and adolescent practitioner series)
Includes bibliographical references and index.
ISBN 978-1-4625-1019-1 (hard cover : alk. paper)
1. Teenagers—Suicidal behavior. 2. Suicidal behavior—Risk factors. 3. Teenagers—
Mental health. 4. Suicide—Prevention. I. Ewell Foster, Cynthia. II. Rogalski,
Kelly M. III. Title.
RJ506.S9K56 2013
616.85′844500835—dc23
2013004793
 About the Authors

Cheryl A. King, PhD, ABPP, is Professor in the Departments of Psy-

chiatry and Psychology at the University of Michigan, where she serves
as Director of the Youth Depression and Suicide Prevention Research
Program and the Institute for Human Adjustment. She is board certi-
fied as a clinical child and adolescent psychologist. Dr. King has a long-
standing record as a clinical educator and public policy advocate, and
has conducted workshops across the United States and abroad on clinical
practice with suicidal children, adolescents, and young adults. She has
also written widely on topics related to youth suicide prevention, includ-
ing research that has informed best practices in suicide risk recognition,
assessment, and intervention with adolescents and young adults. Dr. King
is a Fellow of the American Psychological Association and Past President
of the Society for Clinical Child and Adolescent Psychology, the Asso-
ciation of Psychologists in Academic Health Centers, and the American
Association of Suicidology.

Cynthia Ewell Foster, PhD, is Clinical Assistant Professor in the Depart-

ment of Psychiatry at the University of Michigan and Director of the Uni-
versity Center for the Child and Family. Dr. Ewell Foster has significant
training and experience in providing evidence-based interventions for
youth struggling with depression and suicide risk. She serves as a clini-
cal educator for new mental health professionals in psychiatry, psychol-
ogy, and social work. Her research interests involve ­community- and
school-based interventions for youth at risk for depression and suicide.
v
 About the Authors

Dr. Ewell Foster has recently served as the Evaluation Consultant to the
State of Michigan’s Garrett Lee Smith Suicide Prevention Grant.

Kelly M. Rogalski, MD, is a pediatric psychiatrist and Medical Director

of Outpatient Pediatric Psychiatry at Henry Ford Health System in south-
eastern Michigan, which is a 2011 Malcolm Baldridge National Quality
Award winner for performance excellence and innovation, notably for its
work in improving depression care to reduce suicide. Her research inter-
ests include quality improvement work in behavioral health. Dr. Rogalski
is also a voluntary faculty member at Wayne State University School of
Medicine, where she is involved in teaching medical students, residents,
and nurse practitioner students.

vi
 Acknowledgments

T his book is the culmination of many years of clinical practice

and consultation, teaching, and applied research related to
screening, assessing, and managing the care of teens at elevated
risk for suicide. We have had many influential teachers along
the way, including our students, who have “kept us on our toes,”
challenged us to respond to tough questions and help them with
difficult cases, and shared with us their fresh ideas and clinical
successes. We also owe a debt of gratitude to the many clinical sci-
entists who conducted the rigorous and often painstaking research
that informs practice with these teens and is included within this
book. Finally, we thank our patients and clients—the at-risk teens
and their families—who have been some of our most memorable
teachers. As readers are undoubtedly aware, clinical science often
falls short when we ask, “Exactly what is this teen’s level of risk?”
or “What is the best step to take next for this individual teen, given
these family values and the services available in this community?”
And even when we do have pertinent scientific evidence, no one
disputes the importance of considering the unique backgrounds,
values, and preferences of different teens and families. These teens
and their families continue to teach us about emotional pain, hope,
and the importance of compassion.
Rather than offer prescriptive guidelines, we chose to write an
evidence-informed practitioner guidebook that points to the scien-
tific evidence while also emphasizing compassionate care, the inte-
gration of new scientific findings over time, and consultation with
vii
 Acknowledgments

other professionals. In keeping with this emphasis on consultation,

we wish to acknowledge the extraordinarily helpful input we have
received from many of our thoughtful colleagues in the field. In
particular, we would like to thank Joan Asarnow, Lanny Berman,
Rebecca Fatzinger, Julie Goldstein-Grumet, David Goldston, Greg-
ory Hanna, David Jobes, Anne Kramer, David Litts, Nicole Nugent,
and David Rudd. Each of these individuals reviewed one or more
of the chapters and appendices and provided helpful, constructive
suggestions for improvement. We would also like to acknowledge
the child and adolescent psychiatry fellows in the Department of
Psychiatry at the University of Michigan who reviewed the con-
tent and provided valuable input during their writers’ workshop,
with a special emphasis on how we could make the information
most accessible to clinicians. Finally, completion of this book would
not have been possible without the help of our highly skilled and
thoughtful research assistants, Ryan Hill, Adam Horwitz, and Kiel
Opperman, who assisted with literature reviews, preparing refer-
ences, the creation of tables and figures, and editing.
There are many others who have made critically important
contributions to our thinking and the content of this book, and
who have provided support, guidance, and inspiration to each of
us. Dr. King thanks Dr. Cynthia Pfeffer and Dr. David Brent, who
each served as a role model and research advisor to her at a criti-
cal point during her career, and her generous and supportive col-
leagues and friends in the American Association of Suicidology and
the American Foundation for Suicide Prevention. She also thanks
the survivors of suicide who bear witness to its tragedy and con-
tinue to advocate passionately for continued research and improved
clinical practice. Dr. Ewell Foster would like to thank Dr. Judy
Garber, her first academic mentor, who instilled a desire to under-
stand and, by extension, to help young people at risk for depres-
sion and suicide, and Dr. Joseph Durlak, who inspired a passion
for community advocacy and public health approaches to preven-
tion and intervention. In addition, Dr. Ewell Foster would like to
recognize the community of Garrett Lee Smith grantees across the
nation who are working tirelessly with the support of the Substance
Abuse and Mental Health Services Administration and the Suicide
viii
 Acknowledgments

Prevention Resource Center to build real and lasting capacity for

youth suicide prevention. Finally, she would like to extend heartfelt
thanks to Dr. Cheryl A. King, her mentor for the past 10 years. Dr.
Rogalski would like to thank a dear mentor, Dr. Lisa MacLean, for
advocating for her development throughout residency and beyond.
In addition, she thanks Dr. Ed Coffey for promoting her ongoing
growth and learning during the early years of her career.
Finally, we would like to acknowledge individuals in our per-
sonal lives who have made this book possible.

Cheryl A. King: Throughout the more than 25 years of my work

in youth suicide prevention, my husband, Steve, and my daugh-
ters, Janna and Michelle, have been the foundation and joy of my
life. Thank you! In the whirlwind of an academic’s life—with the
multitasking and deadlines that come with the roles of clinical
researcher, clinician and clinical educator, and administrator—I
have been fortunate to experience much calm and centeredness.
I attribute this to my parents, who taught me to work hard and
embrace commonsense values, and to our growing family, which
embraces connectedness, personal development, and a life of many
adventures.

Cynthia Ewell Foster: Enormous thank-yous to my parents, Mal

and Daisy Ewell, for years and years of unconditional love and
encouragement (and for that college education!), and to my hus-
band, Chuck, and our three amazing kids, Charlie, Virginia, and
Jacob. They definitely add sparkle, fun, and meaning to every day.

Kelly M. Rogalski: Thank you to my husband, Joe, for encourag-

ing my love of learning. From the moment I began this project, he
supported every step. He has been there through the long journey
of medical school, residency, and fellowship; now, as I pursue my
career, he continues to support what is clearly my passion and not
just a job. I am blessed to have Joe balance my serious side and add
fun and spontaneity to create wonderful memories.

ix
 Authors’ Note

W hile this book focuses on screening, assessment, and man-

agement with suicidal teens, we do not intend to define the
standard of care. Our hope is to provide a useful resource for work-
ing with these teens. Each case is unique and presents an individ-
ual set of clinical and risk management issues. Nothing can replace
appropriate training, experience, clinical supervision, and consul-
tation when working with this challenging population of patients.

xi
 Contents

On e Introduction 1
Organization of This Practitioner Guide 3
The Challenges for Practitioners 3
Classification and Definitions 6
A Systematic Risk Assessment
and Care Management Approach 8
Conclusion 11

T wo A Look at Overall Risk and Protective Factors 12

What Are Risk and Protective Factors? 13
How Do We Conceptualize Risk Factors? 14
Risk Factors for Teen Suicide and Suicidal Behavior 15
Protective Factors for Teen Suicide
and Suicidal Behavior 35
Conclusion 36

T h r e e Screening: How We Recognize Elevated Risk 37

Basic Principles of Screening 39
Interview and Self‑Report Screening Strategies 45
Screening Strategies for Your Setting 55
Conclusion 65

Fou r Suicide Risk Assessment and Risk Formulation 67

Basic Principles of Risk Assessment 69
Steps in Risk Assessment and Formulation 72
The Interview as a Primary Risk Assessment Strategy 77
Self‑Report Questionnaires 83
The Mental Status Exam 86
Integrating Information to Formulate Risk 91
Documenting and Communicating Risk Formulation
and Plan 96
Conclusion 102

xiii
 Contents

F i v e Intervention Planning and Care Management 103

Intervention Plans for Teens at Elevated Risk
for Suicide 104
The Importance of Repeated Risk Assessments 118
The Importance of Follow‑Up for No‑Shows
and Referrals 119
Continuing Education, Consultation,
and Collegial Support 120
Conclusion 121

Si x Partnering with Parents and Schools 122

Strategies for Working Effectively with Parents 123
Common Challenging Situations 130
Strategies for Working Effectively with Schools 134
Conclusion 139

S e v e n Legal Issues 140

Patient Suicides and Legal Action 141
Conclusion 149

A ppe n di x 151
A Risk Factor Checklist for Teen Suicidal Behavior 152
and Suicide
B Tracking Form for School‑Based Screening 153
C Suicide Prevention Resources for Schools 154
(Guidelines and Education/Awareness Programs)
D Questions to Ask about Suicidal Thoughts 157
E Teen Suicide Risk Assessment Worksheet 158
F Documentation of Teen Suicide Risk Assessment 161
G SAFE-T Card 162
H Safety Plan Form 164
I Suicide Warning Signs for Parents 166
J Tips for Communicating with Teens 167
K Useful Websites 168
L Evidence‑Based Youth Suicide Interventions 171
M Sample Letter to Formally Request School‑Based Services 174

References 175

Index 201
xiv
 C h apt e r O n e

Introduction

C h apt e r O bj e c t i v e s

Describe objectives and organization of the practitioner guide.

ff
Discuss practitioner challenges inherent in work with suicidal
ff
teens.
Present a classification system for suicidal and self-injurious
ff
behavior.
Present a rationale for evidence-based, systematic approach to
ff
screening, risk assessment, and care management.

W e are writing this practitioner guide to provide you with

both a clear and systematic strategy and a set of practical
tools for identifying and working effectively and safely with teens
at elevated risk for suicidal behavior and suicide. If your practice
includes teens, you almost certainly have worked with these at-
risk teens. A concern about suicide risk—whether due to a suicide
attempt, a text message or diary entry indicating suicidal intent,
or an expression of suicidal thoughts—is the most common mental
health emergency in this age group.