How to Risk Stratify Youth After ED Suicidal Behavior
How should clinicians identify children and adolescents seen in the ED for self-injurious thoughts and behaviors who are most likely to return within 6 months?
Children and adolescents who present to the emergency department with suicidal ideation, suicide attempt, or nonsuicidal self-injury often return within a short period, and risk is concentrated early after the index visit. This guide applies to ED and urgent psychiatric assessment of patients younger than 18 years with self-injurious thoughts and behaviors and helps clinicians focus follow-up on the factors most associated with repeat presentation.
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Identify all SITB presentations at the index ED visit
Classify the presentation broadly as self-injurious thoughts and behaviors, including suicide attempts, suicidal ideation, and nonsuicidal self-injury, because all 3 groups were included in the study outcome framework. Do not assume one presentation type is low risk for return, because 6-month return rates were 21.7% after nonsuicidal self-injury, 25.8% after suicidal ideation, and 25.3% after suicide attempt.
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Use a standardized psychiatric assessment to collect recurrence-risk variables
At the first ED visit, obtain a semistructured psychiatric assessment that captures the clinical and psychosocial variables examined in the study. In addition to diagnosis and current presentation details, specifically document sexual orientation, LGBTIQ+ status, prior suicidal behavior, prior mental health follow-up, previous mental health hospitalizations, comorbidities, eating problems, family conflicts, and whether treatment was adjusted during the emergency visit.
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Prioritize prior suicidal behavior as a major recurrence marker
Treat a history of prior suicidal behavior as a key signal that the patient is at higher risk of returning to the ED for a new suicidal event. In the adjusted model, prior suicidal behavior remained independently associated with return, with an odds ratio of 2.14 and a 95% confidence interval of 1.27 to 3.60.
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Assess sexual orientation explicitly and affirmingly
Include direct assessment of sexual orientation in the ED evaluation rather than inferring risk from other demographic features. Nonheterosexual sexual orientation was independently associated with return in the adjusted model, with an odds ratio of 2.10 and a 95% confidence interval of 1.14 to 3.87, and LGBTIQ+ status and sexual orientation were also associated with return in the Cox analysis.
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Broaden risk stratification to family and clinical complexity factors
Do not limit risk assessment to the index suicidal act alone. In the Cox model, family conflicts, previous mental health hospitalizations, comorbidities, eating problems, previous mental health follow-up, and treatment adjustments during the previous emergency visit were all associated with greater likelihood of return, suggesting that youths with more psychosocial adversity or clinical complexity may need closer monitoring.
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Plan the most intensive follow-up in the first weeks after discharge
Weight the follow-up plan toward the early post-ED period, when recurrence was most concentrated. The survival analysis showed 29 return events by 15 days, 43 by 1 month, and 69 by 2 months, while the overall 6-month return proportion was 25.4%.
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Do not rely on gender identity as a discriminator in this dataset
Avoid using gender identity as a primary factor for predicting revisit risk based on this study alone. The authors reported that gender identity did not appear to be associated with ED revisits in this sample, whereas other factors, especially prior suicidal behavior and nonheterosexual sexual orientation, showed stronger associations.
Clinical Considerations
- This was a single-center study from a tertiary hospital in Madrid, so generalizability to other settings may be limited.
- Some data were collected from medical records, and suicidal intent was not always fully clear from case records, particularly when ideation and self-injury co-occurred.
- The study used clinical diagnoses without standardized rating scales, so the workflow reflects charted clinical assessment rather than scale-based risk prediction.
- Repeat visits may have been underestimated because some patients could have presented to other facilities during follow-up.
Bottom Line
After a pediatric ED visit for suicidal ideation, suicide attempt, or nonsuicidal self-injury, the clearest signals for intensified early follow-up are prior suicidal behavior and nonheterosexual sexual orientation, with added attention to family conflict and overall clinical complexity.
