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Abstract
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The increased prevalence of attempted and completed suicide in childhood and adolescence, combined with recent emphasis on secondary prevention by primary care physicians, underscores the need for effective training of pediatricians and other primary care providers in assessment of suicidal risk. It is probable that psychiatrists will play a leading role in this training. This descriptive study uses interview data from a unique cohort of 19 graduating pediatric residents from 2 programs to document qualitative and quantitative aspects of their clinical experience with suicidal children and adolescents. The implications of these findings for those involved in resident training are discussed in light of pertinent literature.
Suicide is now the third leading cause of death during adolescence and the prevalence of completed suicide among 15- to 24-year-olds has increased two-fold over the last two decades (R1P16951). A recent policy statement from the American Academy of Pediatrics (AAP) emphasized the critical role for pediatricians in both prevention and intervention for suicidal youth (R1P16952). This role is likely to become more important as these physicians become the gatekeepers for referral to specialists, including psychiatrists (R1P16953).
To date, there has been no national training initiative for pediatricians or other primary care physicians involved in the assessment and care of suicidal children and adolescents. The implications for psychiatrists, who have traditionally been called upon to provide training of this nature, have not been discussed in light of what is already known about pediatric practices in this arena.
Though limited, objective data regarding current pediatric practices is of concern. For instance, Hergenroeder et al. reviewed 45 charts of children and adolescents seen in a fully staffed pediatric emergency room for evaluation of suicidal ideation and/or behavior (R1P16954). Of these, 24 were referred directly to the child psychiatry service, with only minimal involvement of the pediatric resident, or were managed only for medical conditions. In 10 of the remaining 21 cases, the residents' notes revealed no indication of past suicide attempts, current suicidal ideation, or any in-depth assessment of the patient's current level of functioning. The authors concluded that "pediatric programs need to emphasize training in suicide interventions and establish a role for the pediatric resident in the assessment process" (R1P16954, p. 791).
The perspective of graduating pediatric residents regarding their own experiences in training have not been addressed in the literature in this country. Nevertheless, a study from Great Britain suggests that resident-level general physicians feel that their training in assessing patients who have overdosed is inadequate (R1P16955). When a cohort of 20 junior medical staff (akin to house staff) were interviewed about their attitudes regarding patients treated in the emergency room for overdose, there was no relationship between their attitudes and the standard of their assessments. Only 25% of those interviewed felt their medical school experience prepared them for assessing suicidal patients as house officers, and a majority spontaneously noted the need for more training in this arena in anticipation of a change of policy under which general physicians would decide which patients were to be seen by a psychiatrist. Chart reviews of patients seen in the emergency room for overdose in Britain reveal similar deficiencies to those just cited (R1P16956).
With the continued rise in rates of suicide and suicide attempts, the shortage of child and adolescent psychiatrists (R1P16957), and the increased emphasis on cost containment necessitating fewer referrals for assessment by specialists, the skills of pediatricians in assessing suicidal children and adolescents are likely to be further tested. It appears that the practice of having pediatricians and other primary care physicians screen most suicidal patients and decide which ones need psychiatric evaluation is likely to soon be the norm in this country. |