Supporting PCPs: Talking Suicide Prevention and Awareness

Suicide prevention in pediatric primary care isn’t just about asking the right questions—it’s about asking them in the right way. As pediatric primary care providers (PCPs), you are often the first point of contact for kids who may be struggling. While all PCPs are comfortable diagnosing an ear infection in their sleep, a child disclosing suicidal thoughts can make anyone feel out of their depth. Even when you’ve got the steps down, like any kind of crisis care, it’s always worth reviewing. The key? Stay calm, be prepared, and have a plan.

Step One: Normalize the Conversation

I shared last week how we can approach mental health conversations in pediatric settings, and that includes talking about suicide. Some PCPs fear that bringing up suicide might plant the idea in a child’s head, or even trigger it. Let’s dispel that myth right now: talking about suicide does not increase risk of suicide. In fact, routine screening and open conversations can be lifesaving.

The American Academy of Pediatrics recommends screening as early as age eight, but younger children can also experience suicidal ideation. By making these questions a normal part of every visit, you’re creating a safe space where children feel comfortable sharing when they’re struggling.

Step Two: Prepare for a “Yes”

What happens when a child says, "Yes, I feel worried all the time," or "Yes, I have thoughts I don’t want to tell you about"? Children take emotional cues from adults, so the best thing we can do is just be prepared for that answer—if we react with fear, they will shut down and never bring it up again. 

The best thing we can do to stay curious instead of showing our worry is practice ahead of time. You might have rehearsed this conversation in the past, or feel ready to now, but it doesn’t hurt to brush up by running through the conversation with a colleague, friend, or family member. Doing this allows the child to be more likely to continue sharing. Breathe, and remember that a child sharing these feelings is significantly safer than hiding them.

Step Three: Move Beyond the Checklist

It’s easy to default to a clinical checklist when discussing suicide:

• Do you have a plan?
• Do you have access to lethal means?
• How often do these thoughts occur?

While structured questions are essential, we’re not filling out a form. Engage kids in a way that feels human:

• “That was really brave of you to tell me. Thank you.”
• “Can you help me understand when these thoughts happen? After a tough day at school? During a fight with a friend?”
• “Do you ever feel like hurting yourself? That could mean things like scratching, pulling your hair, or even snapping a rubber band against your skin.”

Children don’t always recognize self-harm as harmful. By naming specific behaviors, you help them identify what’s happening and give them permission to talk about it.

Step Four: Know Your Limits and Next Steps

Once a child discloses suicidal thoughts or self-harm, the next steps depend on the severity and frequency of these thoughts:

• One-time fleeting thought? Monitor closely and provide mental health resources.
• Recurring thoughts (e.g., twice a week in the last 90 days)? Immediate referral to a mental health professional is necessary.
• Plan in place or high-risk behaviors? This is out of a PCP’s scope—immediate intervention is required, including potential hospitalization.

If you’re in a resource-limited area, telepsychiatry, psychiatric consultation services, and collaborative care models can help bridge the gap. Having a trusted referral network and emergency protocol in place makes these transitions smoother. If you don’t already have a routine for reviewing these protocols, consider setting one. 

Step Five: Medications—Help or Harm?

While medications like SSRIs can be life-changing for kids struggling with depression and anxiety, they come with a known risk: increased suicidal ideation, especially in the first two weeks. That’s why it's best to include a therapeutic intervention alongside medication.

Before starting medication, ensure the child has access to therapy and psychiatric oversight. If local resources are scarce, connecting with a psychiatric consultant is crucial. One of the most dangerous periods of care when a child is depressed is not always when they are deep in sorrow- its when they first start feeling better but still lack strong coping mechanisms.

Step Six: Avoiding Common Pitfalls

• Don’t phrase questions in a way that discourages honesty. Saying, “You’ve never had thoughts of hurting yourself, right?” invites a default “no.” Instead, ask, “Have you ever had thoughts about hurting yourself?”
• Don’t dismiss self-harm as “just for attention.” Self-harm is a serious coping mechanism that indicates deep emotional distress. It must be addressed with the same urgency as suicidal ideation.
• Don’t assume self-harm won’t escalate. Some believe that non-suicidal self-injury (NSSI) doesn’t lead to suicide, but kids can miscalculate, press too hard, or act impulsively. Every case deserves attention and care.

The Bottom Line: Be Ready, Stay Calm, and Follow Through

Suicide prevention starts in the exam room. It’s important to talk about it, but how we talk about it matters. By practicing conversations, normalizing screenings, and having a clear referral process, PCPs can create a system where kids feel seen, heard, and supported.

You don’t have to fix everything in a single visit, but you do have to start the conversation. And that conversation could save a life.

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