Welcome to the training on Youth Suicide: Addressing Risks, Plans and Behaviors provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).
The goal of this module is to support Texas Health Steps providers and others in using a team approach to address the challenge of youth suicide. Providers will learn about screening to identify youth with suicide risk factors; addressing suicidal plans and behaviors; and providing appropriate referrals, ongoing care, and care coordination in a primary care setting.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Summarize risk factors and warning signs of suicide in youth.
- Apply current recommendations to screen all youth for suicidal thoughts and behaviors.
- Examine the role of the medical home in the treatment and ongoing management of care for youth at risk for suicide.
- Formulate a care workflow for youth at risk for suicide in specific office and community settings.
- Apply suggestions for provider self-care in potentially challenging patient situations with youth at risk for suicide.
Note: In this module, the term “parent” also refers to guardians and caregivers. The term “supportive adult” refers to those same individuals plus other important people in the adolescent’s life. The terms “adolescent” and “youth” are used interchangeably in the module to refer to individuals ages 10 through 24 years. Resources listed throughout the module can be accessed through the Appendix on this page.
Please note this module expires on 5/20/2023.
This module was released on 5/20/2020.
Continuing Medical Education
The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Nursing Education.
The Texas Department of State Health Services, Continuing Education Service under sponsor number CS3065 has been approved by the Texas State Board of Social Worker Examiners to offer continuing education contact hours to social workers. The approved status of The Texas Department of State Health Services, Continuing Education Service expires annually on December 31. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Social Work Education.
Certificate of Attendance
The Texas Department of State Health Services, Continuing Education Service has designated 1.50 hour(s) for attendance.
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
Texas Health Steps courses are best viewed using a current browser. If you are using an out-of-date browser or a version of Internet Explorer less than 11, lesson progress and interactive features may not function properly.
Celia Neavel, MD, is director of the Center for Adolescent Health and the GOALS (Generating Outcomes and Liaisons for Students) program at People's Community Clinic, Austin.
Texas Suicide Prevention Initiatives and Resources
- Texas Department of Family and Protective Services. STAR Health Medicaid managed care for children and adolescents in foster care.
- Texas Health and Human Services Commission. Children’s Health Insurance Program (CHIP) and Children’s Medicaid
- Texas Health and Human Services Commission. Crisis Services web page
- Texas Health and Human Services Commission. Local Mental Health Authorities and Local Behavioral Health Authorities
- Texas Health and Human Services Commission. STAR Kids Medicaid Managed Care Program
- Texas Health and Human Services Commission. STAR Medicaid Managed Care Program
- Texas Health and Human Services Commission. Suicide Prevention web page
- Texas Health and Human Services Commission. Texas Medicaid and CHIP Medical Transportation Program
- Texas Health and Human Services Commission wallet card, with suicide prevention phone numbers and other crisis resources that can be printed out and given to parents and youth
- Texas Health Steps Anticipatory Guidance: A Guide for Providers
- Texas Health Steps Periodicity Schedule
- Texas Medicaid & Healthcare Partnership. Online provider lookup
- Texas Suicide Prevention Council website offers:
- A comprehensive suicide prevention Toolkit
- Texas Fact Sheets for Suicide Prevention
- Online training such as ASK about Suicide to Save a Life
- An Information Library with a wide selection of prevention resources, including mobile apps
Mental Health Screening Tools
- Pediatric Symptom Checklist (PSC-17)
- Pediatric Symptom Checklist for Youth (Y-PSC)
- Patient Health Questionnaire (PHQ-9)
- Patient Health Questionnaire Modified for Adolescents (PHQ-A [depression screen])
- Car, Relax, Alone, Forget, Family, and Trouble Checklist (CRAFFT)
- Patient Health Questionnaire for Adolescents (PHQ-A [anxiety, eating problems, mood problems and substance abuse screen])
Psychosocial Screening Tool
- HEEADSSS 3.0 psychosocial interview for adolescents from Contemporary Pediatrics
Maternal Postpartum Depression Screening Tools
- Edinburgh Postnatal Depression Scale (EPDS)
- Patient Health Questionnaire (PHQ-9)
- Postpartum Depression Screening Scale (PDSS)
- American Association of Suicidology
- American Foundation for Suicide Prevention
- Counseling on Access to Lethal Means (CALM), a free online video course offered by the Suicide Prevention Resource Center
- Mental Health First Aid (MHFA) training
- The National Action Alliance for Suicide Prevention
- Substance Abuse and Mental Health Services Administration (SAMHSA) Suicide Prevention
- Suicide Prevention Resource Center, Zero Suicide National Website
- Zero Suicide Institute
Crisis Hotlines, Textlines, and Chats
Crisis Text Line provides free 24/7 crisis support and trains volunteers to support people in crisis
- Text: TX to 741741 for free 24/7 crisis support in the U.S.
- Call: 800-273-8255 (800-273-TALK)
- Chat online: suicidepreventionlifeline.org/chat
Support for people who are deaf or hard of hearing: 800-799-4889
La Red Nacional de Prevención del Suicidio: 888-628-9454
The Trevor Project, a leading national organization that provides crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, queer and questioning young people 24 years and younger.
- Chat online: thetrevorproject.org/get-help-now
- Call: 866-488-7386
- Text: START to 678678
Veterans Crisis Line: Call 800-273-8255, and press 1
- Chat online: veteranscrisisline.net
- Send a text message: 838255
Help Outside the United States
To find a suicide helpline outside the United States, contact Suicide.org for International Suicide Hotlines.
Education and Training
- American Foundation for Suicide Prevention (AFSP) has local chapters throughout Texas that can deliver education programs to schools, workplaces, and communities.
- Columbia Lighthouse Project, affiliated with Columbia University, offers a website that discusses use of the Columbia-Suicide Severity Rating Scale (C-SSRS), an evidence-based tool that anyone can use to assess suicide risk and next steps.
- National Alliance on Mental Illness (NAMI Texas), the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. Local NAMI chapters can deliver education programs to communities.
- The Joint Commission. (2019). R3 Report: Requirement, Rationale, Reference.
- Brown and Stanley Safety Planning Intervention Template
- Project ChildSafe partners with law enforcement in Texas to provide safety kits for firearms, with cable-style gun locks and installation instructions.
- Substance Abuse and Mental Health Services Administration (SAMHSA) webinar to train health-care providers using the Patient Safety Plan toolkit. “The Safety Planning Intervention to Reduce Suicide Risk for People with SMI [serious mental illness]”
- American Academy of Child and Adolescent Psychiatry. (2019). Recommendations for Pediatricians, Family Practitioners, Psychiatrists, and Non-physician Mental Health Practitioners.
- American Academy of Child and Adolescent Psychiatry. (2018). Suicide in Children and Teens. Facts for Families, No. 10.
- American Academy of Pediatrics. (2016). Suicide and Suicide Attempts in Adolescents. Pediatrics 138(1):e20161420
- American Academy of Pediatrics (2012; reaffirmed 2016). Policy Statement: Firearm-Related Injuries Affecting the Pediatric Population. Pediatrics, 130(5).
- American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. (2018). ACOG Committee Opinion: Screening for Perinatal Depression.
- American Foundation for Suicide Prevention (AFSP). (2019). Q&A: AFSP discusses the clinician’s role in suicide prevention.
- American Foundation for Suicide Prevention. (2019). Suicide Statistics.
- Brodsky, B. S., Spruch-Feiner, A., & Stanley, B. (2018). The Zero Suicide Model: Applying Evidence-Based Suicide Prevention Practices to Clinical Care. Frontiers in Psychiatry, 9(33).
- Brown, G., & Stanley, B. (2019). Safety Planning Intervention: A Brief Intervention for Reducing Suicide Risk.
- Centers for Disease Control and Prevention. (2019). Deaths: Leading Causes for 2017. National Vital Statistics Reports, 68(6).
- Centers for Disease Control and Prevention. (2019). Death Rates Due to Suicide and Homicide Among Persons Aged 10–24: United States, 2000–2017. NCHS Data Brief No. 352. Data table for Figure 1. Suicide and homicide death rates among persons aged 10–24: United States, 2000–2017.
- Centers for Disease Control and Prevention. (2019). Suicide Prevention.
- Centers for Disease Control and Prevention. (2019). Ten Leading Causes of Death and Injury.
- Centers for Disease Control and Prevention. (2019). Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students – 19 States and Large Urban School Districts, 2017. Morbidity and Mortality Weekly Report, 68:67-71.
- Centers for Disease Control and Prevention. (2017). High School Youth Risk Behavior Survey Data, Texas Results.
- Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S. Laraque, D., Stein, R. E. K, & he GLAD-PC Steering Group. (2018). Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics, 141(3):e20174082.
- Columbia-Suicide Severity Rating Scale (C-SSRS) – Pediatric version to assess the level of risk and type of services that are needed.
- Columbia-Suicide Severity Rating Scale (C-SSRS). Screen version.
- Columbia-Suicide Severity Rating Scale (C-SSRS). Safe-T with C-SSRS. The SAMHSA SAFE-T risk assessment tool with C-SSRS questions embedded and triage categories.
- Everytown for Gun Safety Support Fund. (2019). The Impact of Gun Violence on Children and Teens.
- Harvard, T. H. Chan School of Public Health. (2020). Recommendations for Clinicians: Lethal Means Counseling.
- Hedegaard, H., Curtin, S. C., & Warner, M. (2018). Suicide rates in the United States continue to increase. NCHS Data Brief, no. 309. Hyattsville, MD: National Center for Health Statistics.
- Kalmoe, M. C., Chapman, M. D., Gold, J. A., & Giedinghagen, A. M. (2019). Physician Suicide: A Call to Action. Missouri Medicine 116(3): 211–216.
- Khangura, S. D., Kanga, I., Seal, K., & Spry, C. (2018). Suicide-Specific Psychotherapy for the Treatment of Suicidal Crisis: A Review of Clinical Effectiveness [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2018 May 28.
- Lindsey, M. A., Sheftall, A. H., Xiao, Y., & Joe, S. (2019). Trends of Suicidal Behaviors Among High School Students in the United States: 1991–2017. Pediatrics, 44(5): e20191187.
- Logan, K., Cuff, S., and Council on Sports Medicine and Fitness. (2019). Organized Sports for Children, Preadolescents, and Adolescents. Pediatrics,143(6) e20190997.
- March, J. S., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., Burns, B. Domino, M., McNulty, S., Vitiello, B., & Severe, J. (2007). The Treatment for Adolescents with Depression Study (TASD): long-term effectiveness and safety outcomes. Archives of General Psychiatry. 2007 Oct;64(10):1132-43.
- Mayo Clinic. (2019). Self-injury/Cutting.
- McCain, J. A. (2009). Antidepressants and Suicide in Adolescents and Adults: A Public Health Experiment with Unintended Consequences? Pharmacy and Therapeutics Jul; 34(7): 355-367, 378.
- Mental Health America of Texas, Texas Suicide Prevention Council, Texas Youth Suicide Prevention Project, and Texas Department of State Health Services. (2015). “Coming Together to Care: A Suicide Prevention and Postvention Toolkit for Texas Communities.”
- National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group. (2018). Recommended standard care for people with suicide risk: Making health care suicide safe. Washington, DC: Education Development Center, Inc.
- National Action Alliance for Suicide Prevention. (2012). National Strategy for Suicide Prevention.
- National Institute of Mental Health. (n.d.). Suicide in America: Frequently Asked Questions.
- Orsolini, L., Valchera, A., Vecchiotti, R., Tomasetti, C., Iasevoli, F., Fornaro, M., . . . Bellatuono, C. (2016). Suicide during perinatal period: epidemiology, risk factors, and clinical correlates. Frontiers in Psychiatry, 7(138).
- Pew Research Center. (2019). What the data says about gun deaths in the U.S.
- Plemmons, G., Hall, M., Doupnik, S., Gay, J., Brown, C., Browning, W., . . . Williams, D. (2018). Hospitalization for Suicide Ideation or Attempt: 2008-2015. Pediatrics, 141(6):e20172426.
- Project ChildSafe.
- Substance Abuse and Mental Health Administration. (2019). Texas Group Promotes Suicide Prevention Among Hispanics.
- Substance Abuse and Mental Health Administration. SAFE-T. The SAFE-T tool can be used in an outpatient setting and offers insight into the extent and nature of suicidal thoughts and harmful behavior.
- Suicide Prevention Resource Center. (2019). Warning Signs for Suicide.
- Suicide Prevention Resource Center. (2019). Zero Suicide Toolkit
- Texas Department of State Health Services. (2019). Youth Risk Behavior Study, September 2018.
- www.dshs.state.tx.us/chs/yrbs/pages/YRBS-Data-Brief/ functional 3/24/20
- Texas Department of State Health Services. (2018). Texas Projections of Supply and Demand for Primary Care Physicians and Psychiatrists, 2017–2030.
- Texas Health and Human Services Commission. Texas Medicaid and CHIP Medical Transportation Program.
- Texas State Plan for Suicide Prevention: Guidelines for Suicide Prevention in Texas. (2018).
- Texas Suicide Prevention. Ask about Suicide (ASK).
- Texas Suicide Prevention. ASK Certification Training.
- The Joint Commission. (2019). R3 Report: Requirement, Rationale, Reference.
- The Joint Commission. (2016). Detecting and treating suicide ideation in all settings. Sentinel Event Alert, Issue 56.
- United Health Foundation and American Association of Public Health. (2020). America’s Health Rankings, 2019. Suicide in Texas.
- U.S. Preventive Services Task Force. (2019). Final Recommendation Statement: Suicide Risk in Adolescents, Adults and Older Adults: Screening.
- ZEST Zero Suicide Toolkit.
- Zuckerbrot, R. A., Cheung, A. H., Jensen, P. S., Stein, R. E. K., Laraque, D., & GLAD-PC Steering Group (2018). Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics, 141(3):e20174081.
The medical definitions in this module were obtained or adapted from Contagion of Violence: Workshop Summary, Evidence-Based Mental Health, the Missouri Department of Health and Senior Services, the National Center for Biotechnology Information, Psychology Today, and WebMD.