The best way to assess for suicidality is by asking the child/adolescent direct questions. Given that suicidality is so common among youth with BP, clinicians treating children and adolescents with the illness should evaluate for the presence of suicidality.64
Assessment of the individuals’ risk for suicidal behavior includes examining for the presence of specific known risk factors (see Risk Factors, above).
Self-administered scales are useful for screening with this population, since research indicates that adolescents disclose suicidality more readily on self-report than they do in a face-to-face interview. Similarly, adolescents are more likely to endorse suicidality if interviewed without a parent/guardian present. In the event that the teen endorses any item on a suicidality scale, it is strongly recommended that the clinician follow up with the patient regarding his/her safety. It is important to note that there is no evidence indicating that asking about suicidal thoughts or behaviors precipitates suicidality.
Thorough assessment of suicidal ideation includes questions regarding both severity (intent) and pervasiveness (frequency and intensity). Suicidal ideation characterized by a high degree of severity and pervasiveness is associated with a greater likelihood of suicide attempt in adolescents.29
The clinician should also conduct a thorough and detailed review of prior suicidal behavior.
Suicidal intent is the extent to which the individual wishes to die. Given findings that adolescents may disclose suicidal ideation on self-report ratings but deny this information during interview, assessment of suicidal risk should incorporate both means of assessment.
With regard to suicidal intent, the clinician should explore four components:65
(1) belief about intent (ie, t he extent to which the individual wished to die), (2) preparatory behavior (eg, giving away prized possessions; writing a suicide note), (3) prevention of discovery (ie, planning the attempt so that rescue is unlikely), and (4) communication of suicidal intent. High intent, as evidenced by expressing a wish to die, planning the attempt ahead of time, timing the attempt to avoid detection, and confiding suicide plans before the attempt, is associated with recurrent suicide attempts and with suicide completion.
Suicide Plan and Access to Means
Assessment should include inquiry regarding specific plans for inflicting self-harm as well as access to means considered (see Means Restriction, below).
Suicide attempts of high medical lethality (eg, hanging, shooting) are frequently characterized by high suicidal intent, and individuals who use more medically lethal means are at higher risk of completing suicide. However, evidence also indicates that an impulsive attempter with relatively low intent but ready access to lethal means may also engage in a medically serious, and even fatal, attempt.30
The most common precipitants for adolescent suicidal behavior are interpersonal conflict or loss, most often involving a parent or a romantic relationship. Legal and disciplinary problems also frequently precipitate suicidal behavior, particularly among youth with comorbid conduct disorder and substance abuse. Precipitants that are chronic and ongoing, especially recurrent physical or sexual abuse, are associated with poorer outcomes, including recurrence of suicidal behavior and even subsequent completion.30
Motivation is the reason the individual cites for his/her suicidality. Individuals with high suicidal intent indicate that their primary motivation is either to die or to permanently escape an emotionally painful situation, and these youth are at elevated risk for reattempt.66
Many youth who attempt suicide report that they are motivated by the desire to influence others or to communicate a feeling. Understanding the motivation for suicidal behavior has important implications for treatment, as intervention may focus on helping youth identify their needs more explicitly and find less dangerous ways to get their needs met.
The consequences of suicidality refer to any environmental contingencies that occur in response to suicidality. Particularly salient are whether there are naturally occurring contingencies in the environment that reinforce suicidal behavior (eg, increased attention and support, decreased demands and responsibilities). However, positive reinforcement from the environment does not necessarily indicate that the individual acted purposefully to gain the reinforcement.