Children’s Hospital Colorado Research Outlines First Pediatric Classifications for Suicide Risk in Adolescents and Kids

Today, pediatric experts from Children’s Hospital Colorado announced published research in the Journal of the American Academy of Child and Adolescent Psychiatry that identifies five classifications of youth who have died by suicide. Using 10 years of national suicide data, Joel Stoddard, MD, child and adolescent psychiatrist at Children’s Colorado, and his team found that nearly half of youth who died by suicide did not have clinical contact or a known risk of suicide. These findings are critical for recommending new and increased suicide interventions for youth. 

Findings will improve earlier detection and intervention

"In order to help kids now, we need to dig into the mountain of data available to us to learn about youth who are at risk of dying by suicide," said Dr. Stoddard, who is also an associate professor of psychiatry with the CU Anschutz School of Medicine. "Not every child who dies by suicide has the same story. This research looks at the whole person and gives primary care providers, caregivers who work with kids and pediatric experts a greater understanding of suicide risks that are specific to youth."

Because of the pressing nature of youth suicide, it became imperative to Dr. Stoddard and his team to understand risk factors and contextual characteristics in young people to identify warning signs of suicide and implement new focused prevention efforts. Previous research has focused on analyzing adult populations who have died by suicide. Adult classifications, or profiles based on shared characteristics, improve the identification of suicide risk and prompt tailored intervention strategies for adults based on factors like demographics, psychological conditions, life circumstances, toxicological findings, mental health and substance use comorbidities, physical health issues and alcohol-related crises. These profiles provide insights into the varying pathways that lead adults to suicide, and now experts have a way of understanding those insights for youth.

Kids are different and need different care

"Youth face a unique set of pressures and vulnerabilities that are not typically seen in adult populations, or that may manifest differently due to developmental and environmental factors," said Dr. Stoddard. "This research underscores the importance of early identification because by knowing how others have passed away, we can work to prevent this harm in the future. We not only want to keep kids from dying — we want to help them thrive at home, in school, and with their friends and family. Earlier intervention helps connect kids to treatment more quickly so they can grow into adulthood with the foundations they need.”

Research-driven classifications 

Dr. Stoddard and his team identified at least five subgroups of youth who had died by suicide from national data.  These classifications group the behaviors or stories of individuals who have died by suicide to reveal risk factors pediatric experts should look for. For example, the Hidden and Surveillance classes represent almost half of suicides, prompting the recommendation for greater universal screening. The classifications are explained below:

• Class 1, Crisis: These young people experienced a standalone acute interpersonal or school-related crisis. They did not present with prior suicidal thoughts or behaviors or med-psych challenges. This group of youth are most familiar to hospital emergency providers, as a crisis could be a common first reason for medical admission. An example crisis would be a young person experiencing a first relationship breakup.
• Class 2, Disclosing: These young people told someone about their suicidal thoughts. When people express distress, it is important for trusted adults to pay attention to their words and take appropriate next steps. Colorado’s Safe2Tell program is a model for other states, as its reporting system allows anyone to anonymously report concerns regarding their safety or the safety of others with quick intervention follow-up. This classification reveals a need for improved education around resources and interventions available to youth who disclose thoughts of suicide.
• Class 3, Hidden: These young people do not have any recorded risk factors and have minimal contact with the healthcare system. These youth would often be identified in the healthcare system while presenting for other physical symptoms (such as a broken arm), and their risk of suicide is not obvious. Most of these young people were predominantly male and more likely to use firearms.
• Class 4, Identified: These young people experience chronic crises and familial challenges and/or were frequent utilizers of the mental health system. Most of these young people were female and died by asphyxia or ingestion.
• Class 5, Surveillance: These young people were identified as having died by suicide through the state or local county coroner’s reporting, with no other reportable information shared about their death. When there are systematic gaps in reports to the CDC by the state, a youth may be classified in this way. It is important to note: this class number is much lower in Colorado, as Colorado has been a leader in participating in the National Violent Death Reporting System (NVDS) for more than 20 years. Colorado’s consistent recordkeeping and leadership in creating partnerships with county coroners has allowed for greater understanding of how and why a person died.

Investing in suicide prevention at Children’s Colorado 

In September, Children's Colorado announced that The Anschutz Foundation generously committed a challenge donation to the University of Colorado Anschutz, with Children’s Colorado receiving funding directed to supporting the mental health of children across the region. At Children’s Colorado, the investment will first go toward suicide prevention. These classifications assist public health and education systems in refining strategies for earlier upstream detection of suicidality and intervention beyond traditional mental health care.

Below are Children's Colorado's research-driven recommended actions that can be implemented in the community, schools, primary care offices, places of worship, homes and more:

• Universal suicide risk screening: Many young people who died by suicide lacked prior contact with the mental health system. It is important for screening to exist in health care and in community- and school-based settings.
• Safe Firearm Storage and Counseling: Research shows that having firearms in the home increases the risk of unintentional injuries and deaths, as well as suicide and homicide. It is essential to normalize having conversations about gun safety and access to firearms in your home or the homes of friends and families, especially during periods of crisis or higher risk. Children’s Colorado recommends integrating counseling on firearm safety and safe storage of lethal means into routine primary care, given the increased usage of firearms in death across all five classifications of youth suicide. Both the Anschutz Medical Campus and the Colorado Department of Public Health and Environment have safe storage guidance:
  • CDPHE Secure Firearm Storage
  • Department of Emergency Medicine: Colorado's Safe Storage Laws
• Crisis-oriented outreach: Colorado has lower rates of crisis-classified deaths, likely due to the state’s crisis-oriented outreach interventions. Communities and states can implement interventions like text-based support (e.g. Colorado 988), peer disclosure programs (e.g. Safe2Tell) and rapid crisis counseling (e.g. IMatter or the Second Wind Fund) to urgently assist youth in acute relational or academic crises.
• Enhanced surveillance and data quality: From a state policy perspective, it would be advantageous to strengthen death scene investigation protocols and reporting standards to reduce missing data on young people who have died by suicide. Data informs research, which improves interventions recommended to save kids’ lives.
• Integrated care for high-risk classifications: It is important to follow up with youth who are already in treatment (those who identify with the Disclosing or Interpersonal classification) after they graduate from a treatment program or recommend integrated care models that address both chronic mental health needs and acute stressors. 
• Policy and research innovations: Researchers are looking into how they can utilize artificial intelligence, machine learning and mixed-data approaches to learn which patterns are most likely to lead to a suicide attempt and predict suicide risk in kids. Other policy opportunities could be found in standardizing toxicology testing and reporting to clarify substance use patterns in the Hidden and Surveillance Classifications. 

A model for the future

"Pediatric suicide rates still remain high, as one young person lost is one too many," said Ron-Li Liaw, MD, Mental Health-in-Chief at Children’s Colorado. "I am proud of Children’s Colorado for leading the way in translating research and data collection into actionable policy and intervention recommendations that should be implemented across the continuum of mental health care in Coloradro, primary care, schools and all mountain west communities. With youth suicide reporting to be on the decline, we can consider the effectiveness of these interventions already happening in our hospital and across our state. Other states can look to Colorado as a model for recognizing the need for greater investment, time and energy in understanding youth mental health so we can continue improving the prevention of youth suicide."

To learn more about investing in mental health research and prevention, visit Join the Movement: Kids’ Mental Health Can’t Wait. To learn more about pediatric mental health services available at Children’s Colorado, visit childrenscolorado.org.