#174: Suicide Prevention and Safety Planning: Approaching Adolescent Mental Health Crises

April 15, 2026 | By Hartlee Lidsky

Audio

Uh oh, your patient answered yes to Question #9 on the PHQ-9? We join John Ackerman, PhD, ABPP and Elizabeth Kleinhenz, MSW, MPH, LISW from the Center for Suicide Prevention and Research at Nationwide Children’s Hospital to shed light on non-suicidal self-injury, suicide risk assessment, and safety planning in adolescents. From universal screening to individualized safety plans, this episode will leave you feeling more confident and equipped to handle mental health crises.

Suicide Prevention and Safety Planning Show Notes

Non-suicidal self injury

What is non-suicidal self injury? 

Non-suicidal self injury (NSSI) is any time an individual intentionally harms themselves without an intent to die. One in five teens has engaged in NSSI.

What’s the difference between NSSI and suicidality? 

Intent is more important than behavior. If someone causes harm to themself but does not intend to die, that’s NSSI. If someone is thinking about harming themself and any part of them hopes that action might result in their death, that’s suicidal ideation. If they go through with that action, that’s suicidal behavior. 

NSSI is a risk factor for suicidality, particularly when it occurs at younger ages and for long periods of time. NSSI can lower future inhibition for self-harm and can escalate to suicidal behaviors. 

Why do people engage in NSSI? 

Typically it’s a maladaptive coping mechanism. Common motivations include regulating strong emotions, regaining a sense of control, or a desire to “feel something.” 

Not all people with NSSI have depression. Common mental health conditions that can be associated with NSSI include depression, anxiety, impulsivity, trauma, or repetitive body-focused behaviors (e.g. skin picking, hair pulling). 

Approach to NSSI in the clinic: 

1. Be curious if you’re noticing physical exam signs that make you worried about NSSI.
2. Ask directly whether intent is suicidal or non-suicidal. 
3. Review symptoms that might be driving NSSI.
4. Screen for suicidal ideation. 
5. Brief intervention to brainstorm safer alternative coping skills.
6. Talk about treatment options, typically starting with cognitive-behavioral therapy (CBT) or dialectical behavioral therapy (DBT) +/- medications for mood disorders. 

Suicidality

What is suicidal ideation? 

Suicidal ideation refers to thoughts of wishing to be dead or end one’s life. 

Suicidality is a spectrum, and can vary in intensity, duration, behavior, and associated symptoms. As severity, duration, and specific planning increase, the likelihood of suicidal behavior also increases.

Suicidality is common in teenagers. Approximately one in five high school students have seriously considered suicide. Only about half of parents are aware their children are experiencing thoughts of suicide. 

Who is at risk for suicidal ideation or death by suicide? 

Notable risk factors for dying by suicide:

• male sex
• minority racial identity (Black, American Indian or Alaskan Native)
• living in rural areas
• LGBTQ+ identity
• physical or developmental disabilities
• substance use
• history of trauma or abuse (including foster care or juvenile justice involvement)
• history of suicide attempt or NSSI
• family history of suicide
• access to lethal means

However, predicting which individual people will experience suicidal ideation or engage in suicidal behavior is almost impossible. Because we can’t predict who will be affected, universal screening is recommended. 

How should we screen for suicidal ideation? 

The AAP recommends universal screening for all children starting at age 12 during well-child visits and acute visits associated with any behavioral health concerns. They also recommend screening during ED visits and hospitalizations.

Expert tip: Asking teens about suicide does NOT increase suicidal thoughts or behaviors. Evidence shows that screening reduces suicidal ideation and distress. 

Suicide screening tools

A popular screening tool is the PHQ-2 or PHQ-9, which is commonly used in primary care settings to screen for depression. This tool can be useful, but can miss patients who have suicidal ideation without depressed mood. 

The AAP, NIMH, and Dr. Ackerman suggest using the Ask Suicide-Screening Questions (ASQ) tool to screen for suicide risk. The ASQ is a brief validated screening tool to identify patients at risk for suicide. A “yes” response to one or more of the four questions identified 97% of youth ages 10-21 at risk for suicide. 

Figure reproduced from the NIMH ASQ Toolkit.

Expert tip: Suicide risk assessment is like an EKG. It mostly tells you how someone is doing in the current moment, and it may not always capture prior or future risk.

How do we assess suicide risk? 

The terms “active” and “passive” suicidal ideation are commonly used, but they are inconsistently defined and don’t reliably predict risk. 

More specific tools exist for risk stratification. The Columbia-Suicide Severity Rating Scale (C-SSRS) can identify patients at high risk of death by suicide who require immediate intervention. This tool involves 6 yes/no questions. It is available in more than 150 languages. 

Figure reproduced from The Columbia Lighthouse Project. 

Approach to suicidal ideation in clinic: 

1. React compassionately and validate the patient for sharing their experience with you.
2. Ask basic HPI questions about suicidal thoughts, such as onset, severity, frequency, and history of suicide attempts.
3. Assess risk factors.
   1. Mental health conditions
   2. Mental health symptoms, especially auditory or command hallucinations
   3. Family history of suicide
   4. History of NSSI
   5. Access to lethal means
4. Assess protective factors.
   1. Reasons for living
   2. Social support from peers and adults
   3. Support from mental health professionals
   4. Future orientation
5. Conduct a mental status exam.
6. Disclose to the parent(s).
7. Engage the patient and family in safety planning.
8. Determine risk level and decide appropriate level of care.

Template: SAFE-T Suicide Assessment by SAMHSA or the Brief Suicide Safety Assessment can be used for risk assessments in clinical settings. 

Suicide risk assessment is a clinical judgement of patient’s current symptoms and the balance between risk and protective factors. Tools like the C-SSRS and SAFE-T can help providers determine this balance. 

Elizabeth suggests definitely escalating care if any of these red flags are present:

• Current suicidal ideation during the clinical encounter
• Dysregulated or unstable mental status
• Continued access to lethal means
• Unwillingness or inability to safety plan
• Family doesn’t feel safe going home 

Expert tip: When escalating care, Dr. Ackerman suggests arranging a warm handoff with a behavioral health crisis provider if at all possible. While sending someone to their local emergency department is never wrong, proactively setting up alternative crisis referral pathways can lead to better patient experiences and outcomes.

Safety planning

What should a safety plan include?

1. Triggers for suicidal ideation
2. Warning signs of distress or suicidal ideation
3. Coping skills
4. Trusted adult supports, both at home and school
5. Environment safety precautions (e.g. restricting access to lethal means, increasing supervision, initiating regular conversations about mood and suicide)
6. Next steps in case of a crisis (e.g. 988, local crisis center, 911)

Template: 988 Suicide Lifeline safety plan

Expert tip: The best safety plans are realistic and individualized. Encourage kids to incorporate coping skills or social supports that actually work for them, not what they think the “right answer” might be.

Summary:

Uh oh, your patient answered yes to Question #9 on the PHQ-9? We join John Ackerman, PhD, ABPP and Elizabeth Kleinhenz, MSW, MPH, LISW from the Center for Suicide Prevention and Research at Nationwide Children’s Hospital to shed light on non-suicidal self-injury, suicide risk assessment, and safety planning in adolescents. From universal screening to individualized safety plans, this episode will leave you feeling more confident and equipped to handle mental health crises.

Suicide Prevention and Safety Planning Pearls

1. Intent matters. If any part of a patient hopes self-harm might result in death, that’s suicidal ideation. 
2. Asking about suicide does not cause suicidal ideation. Ask every patient using direct language about suicidal thoughts.
3. Use the ASQ to screen all patients age 12 and older. The PHQ-9 alone can miss suicidal ideation in patients without depressed mood.
4. Assess suicide risk using a validated tool like the C-SSRS, BSSA, and/or SAFE-T to determine disposition. . 
5. The best safety plans are realistic and individualized. Help patients and families identify coping strategies and supports they will actually use.

Links

Suicide and Suicide Risk in Adolescents

AAP Clinical Report on suicide screening and prevention. 

The Columbia Protocol for Healthcare and Other Community Settings

Tools related to the C-SSRS, including badge cards, templates for assessing risk and protective factors, templates for clinical documentation, and adapted scales for different care settings, follow-up encounters, and younger children. 

Youth ASQ Toolkit – National Institute of Mental Health (NIMH)

Tools for using the ASQ in practice, including clinical workflows, nursing and provider scripts, informational materials for parents, and additional patient resources. 

Stanley-Brown Safety Planning Intervention

Template and tools for safety planning.

988 Lifeline

24/7 crisis lifeline for patients experiencing mental health crises or suicidal thoughts, including call, text, and chat options.

The Trevor Project

Support for LGBTQ+ patients, including a 24/7 crisis line. 

American Foundation for Suicide Prevention

The Kids Mental Health Foundation

Organizations that support local and national advocacy efforts related to suicide prevention and mental health. 

Goal

Listeners will be able to identify, assess, and respond to suicidal ideation and non-suicidal self-injury in adolescent patients, improving clinical confidence and quality of care in primary care, emergency, and inpatient settings.

Learning Objectives

After listening to this episode, listeners will…

1. Distinguish between non-suicidal self-injury (NSSI) and suicidal ideation based on intent and clinical presentation.
2. Identify risk and protective factors associated with suicidal ideation and death by suicide in adolescents.
3. Apply validated screening tools to assess suicide risk in clinical settings.
4. Recognize red flags that warrant escalation of care and describe strategies for warm handoffs to behavioral health crisis providers.
5. Construct an individualized safety plan in collaboration with an adolescent patient and their family.

Disclosures

Dr Ackerman and Elizabeth Kleinhenz report no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Lidsky H, Nwora C, Ackerman J, Kleinhenz E, Berk J, Chiu C, Masur S. “#174: Suicide Prevention and Safety Planning: Approaching Adolescent Mental Health Crises”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ April 15, 2026.