child (What did the child think or hope would happen? Did the child take all the pills that were available? Did he or she expect to wake up? Did he or she tell anyone after taking the pills? Did he or she leave a suicide note? Now that he or she is awake, is the child pleased or displeased to be alive? Does he or she intend to try again?) Children who threaten suicide without making an actual attempt should also be questioned carefully about suicidal intent (How long has the child considered suicide? What methods? When will this take place? Previous attempts? How about other family members?) Psychotic and depressed children, especially when the parents appear unable to supervise the child, should elicit particular concern Assessment of the child’s level of impulsivity is also important ( Table 126.16 ) Does the attempt appear to have been impulsive rather than planned? Is there a history of prior impulsive behaviors? Is there evidence of impulsivity during the ED interview? TABLE 126.14 CHILD AND ADOLESCENT SUICIDE: ASSESSING MEDICAL LETHALITY Vital signs Level of consciousness Evidence of drug/alcohol intoxication (e.g., pupils, smell on breath) Need for emesis, lavage, or catharsis Acute medical complications (cardiac, respiratory, renal, neurologic) Indications for medical hospitalization, including intensive care Residual abnormalities TABLE 126.15 CHILDHOOD AND ADOLESCENT SUICIDE: ASSESSING SUICIDE INTENT Circumstances of suicide attempt Nature of suicide attempt (e.g., ingestion vs violent means) Use of multiple methods Method used to extreme (all vs some pills ingested) Suicide note written Secrecy of attempt (attempt concealed vs revealed) Premeditation (long planned vs impulsive attempt) History of prior attempts Child self-report Premeditation of attempt Anticipation of death Desire for death Attempt to conceal attempt Nature of precipitating stresses Child’s mental status Orientation/cognitive intactness Presence/absence of psychosis Manner of relating to physician Current suicidality Response to being saved/being unsuccessful in attempt Active plan for another attempt Readiness to discuss stresses Readiness to accept external and family support Nature of orientation toward future The physician should ask the child and family about possible precipitating events to determine what changes in the environment may be needed The strengths of the family should be assessed to determine whether sufficient social support exists to allow for outpatient management ( Table 126.17 ) The ACEP online suicide assessment and treatment tool can be accessed at https://acep.org/patient-care/iCar2e/ Management Evaluation for Hospitalization No universally agreed-on criteria have been established for when to hospitalize a child with suicidal behavior and when they can be safely managed on an outpatient basis Garfinkel and Golombek identified seven areas to assess to determine whether hospitalization is indicated ( Table 126.18 ) The degree to which the family can commit to support the child’s safety and well-being and other resources (extended family, neighbors, peers, and teachers) must be assessed The decision to hospitalize the child is made when the child’s safety is still in doubt after these questions have been answered TABLE 126.16 CHILDHOOD AND ADOLESCENT SUICIDE: ASSESSING IMPULSIVITY Evidence of impulsive suicide attempt History of prior impulsive behaviors Evidence of impulsivity during interview TABLE 126.17 CHILDHOOD AND ADOLESCENT SUICIDE: ASSESSING STRENGTHS AND SUPPORTS Strengths and assets of child Ability to relate to physician Ability to rely on parents in crisis Ability to acknowledge problem Positive orientation toward future Strengths and assets of family Commitment to child Ability to unite during crisis Problem-solving abilities Capacity to supervise child (support and limits) Ability to use external supports Nature of external supports Outpatient psychiatrist/family physician Extended family Neighbors/other significant adults Religious community Self-help groups Any suicide attempt deserves a thorough assessment by the emergency physician and a complete psychiatric consultation Hospitalization should be used in the circumstances listed in Table 126.19 Initiating Treatment If inpatient treatment is required, the child and family should be informed about the goals of hospitalization and the active role of the family in the treatment emphasized Instances in which the child or parents not agree to hospitalization, involuntary commitment may be needed as a last resort Outpatient management of suicidal behavior becomes feasible when (i) the child and family are cooperative and engageable; (ii) the attempt is determined not to have been too serious in terms of intent/medical lethality; ... Religious community Self-help groups Any suicide attempt deserves a thorough assessment by the emergency physician and a complete psychiatric consultation Hospitalization should be used in the