Mental Health Blog

PCPs Are on the Front Lines of Suicide Prevention: Tools to Feel More Confident Having the Hard Conversations

• September 12, 2025
• The REACH Institute
• Assessment & screening, Child mental health, High-risk children & youth, Pediatric primary care, Suicide

“The first time you ask a kid about suicide, it’s scary,” explains Eugene Hershorin, MD, a developmental pediatrician and REACH faculty member. “But navigating that fear and asking the question can save a child’s life.” 

Research shows that primary care providers have a critical role to play in suicide prevention. Among youth, 80% of those who died by suicide had seen a primary care physician in the past year. Among all ages, 45% of people who die by suicide will have seen their primary care provider within the past month. Research also shows that asking about suicide does not increase suicide risk—and can even lower risk, especially among adolescents. 

We asked Dr. Hershorin to walk us through the tools and strategies that can help providers feel more confident integrating regular suicide screening into their pediatric practice. 

Managing Barriers to Pediatric Suicide Screening

Clinical guidelines recommend that pediatric patients—especially adolescents—be screened regularly for suicide risk. But as Dr. Hershorin points out, clinicians may face both emotional and practical barriers when it comes to pediatric suicide screening. 

Dr. Hershorin shares that it’s normal for clinicians to be afraid when they first start asking pediatric patients about suicide. The best way through is deciding that it’s important enough to ask anyway. “I’m not sure asking kids about suicide is ever going to be comfortable,” he explains. “But after you have done it a few times, it does get less scary.” 

In fact, Dr. Hershorin points out that clinicians have learned to ask a lot of uncomfortable questions to adolescent patients. Are you having sex? Are you doing drugs? These questions are difficult for similar reasons: What should clinicians do if the answer is yes? 

The good news is that there are evidence-based tools, detailed below, that are proven to help clinicians determine appropriate next steps to keep patients safe.

Using these tools, however, takes time. Dr. Hershorin explains that the minute a child says, “Yes, I’m depressed and have thought about suicide,” the scheduled visit will take significantly longer. Providers should expect to spend extended time on further screening with the patient alone, followed by planning next steps with the patient and their family. This can be especially challenging when appointments are generally scheduled in 15 or 20-minute increments. 

Dr. Hershorin advises clinicians to think through an advance plan for how they will manage this. For example, the clinician could excuse themselves to inform office staff of the situation and ask them to move around other patients on the day’s schedule. 

Navigating a “Yes” Answer When Screening for Suicide

The first tool to use for suicide screening is the ASQ (Ask Suicide-Screening Questions) Suicide Risk Screening Tool. The ASQ consists of five short questions. If a patient answers no to the first four questions, then they are low-risk and safe to go home. 

If a patient answers yes to any of the first four questions, then clinicians should ask question five: Are you having thoughts of killing yourself right now? If a patient answers yes to this question, they are at acute risk of suicide and clinicians should send them to the ER, potentially in an ambulance. 

Dr. Hershorin explains that it can be especially challenging to determine next steps when the child answers yes to suicidal thoughts, but no to question five (Are you having thoughts of killing yourself right now?). This child might say, “Yes, I’ve thought about suicide. I even made a plan. But I’m not thinking about it right now.” 

To determine the safest course of action for these “in between” children, clinicians should use the ASQ Brief Suicide Safety Assessment (BSSA). The BSSA enables clinicians to sort children at risk of suicide into two groups: 

• Those at acute risk of suicide who should be sent to the ER for emergency psychiatric care. 
• Those at lower risk who can be sent home with a safety plan and follow-up check-ins already scheduled. 

Dr. Hershorin explains that the BSSA is not a scored screening tool. Instead, clinicians should use each question to help assess the risk of the child attempting suicide today, tomorrow, or in the future. “If at the end of the BSSA, you are worried about the child in general but not today, then you can bring in the parents, create a safety plan, schedule a follow-up in a few days, and still send the child home with their caregivers.” 

Creating a Safety Plan with Patients and Families

After completing the full screening process, any child at risk of suicide who is not sent to the ER will need a safety plan. REACH recommends using the Brown Safety Planning Template. 

The safety plan should be developed with the patient and their family together. “I’ve never had a kid say no to bringing their parents in to share what is going on and create a safety plan,” explains Dr. Hershorin. 

A safety plan helps patients and their families identify if suicidal thoughts are getting worse, what the patient can do to distract themselves, and who they can go to for support and emergency help. 

Dr. Hershorin also makes sure parents and caregivers understand what it takes to make the home environment safer for the child. “We talk about removing access to anything that can be used to commit suicide. This includes firearms, ropes and strings, knives and other sharp objects, prescription medications, and even over-the-counter medications, like Tylenol. There is also a risk of suicide by car to be aware of.” 

At the bottom of the safety plan template, clinicians should guide patients in articulating the most important thing in their lives that is worth living for. 

Once complete, providers should be sure that the child and their parents each have a copy of the safety plan. In addition to having a hard copy, Dr. Hershorin recommends patients and family members also take a picture of the plan on their phone, so they can easily reference it whenever needed. The plan can also be scanned into the patient’s medical record. 

Tips for Navigating the Tough Conversations 

Dr. Hershorin advises that it’s normal to feel uncomfortable talking to pediatric patients about suicide. Clinicians can read screening questions directly off of forms, explaining that “I’m reading these questions to you because it’s so important that I do this in a thorough and safe way because I want to keep you safe.” 

Clinicians should also be prepared that patients may open up to them in unexpected ways. “If you’re a pediatric primary care provider, you know how to talk to kids,” shares Dr. Hershorin. “Kids who are having suicidal thoughts may be relieved to finally have someone they trust to talk to about feelings they’ve been holding inside for a long time.” 

Resources

• The ASQ Suicide Risk Screening Tool, Brief Suicide Safety Assessment, and Brown Safety Plan Template can all be found on REACH’s rating scales resource page. 
• REACH’s article on when to send a child to the ER for suicidal ideation provides detailed guidance on making the decision. 
• Caring for the mental health needs of patients can take a toll, and it’s important that providers are also prioritizing self-care. Read ​​Burnout, Mental Health, and Practical Tools for Pediatric Providers on the REACH Mental Health Blog, and visit the ProQOL website for more resources to help you navigate burnout, compassionate fatigue, and more.
• Safety planning apps can also be a valuable tool:
  • iOS:
    • Stanley Brown Safety Plan (green plus icon)
    • Suicide Safety Plan (blue plus icon)
  • Android:
    • Suicide Safety Plan (via MoodTools)