Study Background
Suicide remains one of the leading causes of death among adolescents in the United States, with the emergency department (ED) frequently serving as a critical contact point for youth at risk. An essential suicide prevention strategy endorsed by the National Institute of Mental Health (NIMH) Emergency Department Suicide Risk Screening Pathway involves lethal means safety counseling, which aims to limit access to potentially fatal means, particularly firearms, during times of suicidal crisis. Despite recognized efficacy, the optimal characteristics of lethal means safety counseling interventions tailored to the emergency setting and adolescent populations remain underexplored. Understanding the perceptions and needs of teens and their caregivers who have lived experience with suicidality and firearm access is paramount to developing effective, acceptable, and equitable counseling tools that can be feasibly implemented in busy ED environments.
Study Design
This qualitative study was conducted at a tertiary care children’s hospital emergency department from September 2024 through June 2025. The study enrolled patients aged 10 years and older, all screened for suicide risk using the validated Ask Suicide-Screening Questions (ASQ) tool. Eligible participants included teens aged 13 to 17 years who had a nonacute positive ASQ screen and self-reported firearm access at home, along with their caregivers. Enrollment prioritized English-speaking individuals to facilitate detailed interviews.
Separate semistructured interviews were conducted with teens and caregivers to capture their unique perspectives without bias. A total of 33 interviews were completed, including 19 caregivers, 14 teens, and 14 teen-caregiver dyads. Two study team members independently performed inductive coding on transcribed interviews, followed by content analysis to identify emergent themes relating to lethal means safety counseling in the ED.
Key Findings
Thematic analysis generated three overarching themes illuminating the perceived value, characteristics, and challenges of lethal means safety counseling from teen and caregiver viewpoints.
1. Benefits and Emotional Impact of Counseling: Participants consistently emphasized that lethal means safety counseling is beneficial not only for risk reduction but also for emotional support. It conveyed a sense of care and attention from healthcare providers, helping families feel “seen” and understood during vulnerable moments. Teens appreciated counseling that acknowledged their feelings while affirming their importance.
2. Preferred Counseling Tool Characteristics: Participants identified crucial elements for an effective counseling tool in the ED context. These included the use of technology (e.g., digital interfaces or apps) to engage teens comfortably and efficiently; straightforward, jargon-free language; supportive, nonjudgmental messaging; consideration of equitable access across diverse backgrounds; and inclusion of an actionable safety plan tailored to individual family circumstances. Participants stressed that tools should be concise given ED time constraints but comprehensive enough to guide meaningful family discussions.
3. Barriers: Family Dynamics and Autonomy: A significant challenge emerged regarding balancing teen autonomy with safety considerations. Families vary widely in communication styles, cultural norms, and decision-making patterns, complicating lethal means safety planning. Some teens expressed concerns about privacy and feeling controlled, while caregivers sought reassurance about securing firearms effectively. Navigating these dynamics requires sensitive, individualized approaches that respect adolescent autonomy while ensuring safety.
Expert Commentary
These findings underscore lethal means safety counseling as a critical and high-yield component of adolescent suicide prevention in the emergency setting. Integrating the lived experiences of teens and caregivers reveals practical insights that can enhance counseling effectiveness and acceptance. Incorporating technological adjuncts may improve engagement, while straightforward, supportive communication can mitigate stigma and resistance. Addressing family-specific factors and autonomy concerns is essential to foster collaboration and adherence to safety plans.
Current clinical guidelines advocate for lethal means counseling but offer limited guidance on implementation nuances tailored to family dynamics. This study offers valuable direction for developing family-centered interventions that can be feasibly embedded into ED workflows without adding burden to clinicians or families. Limitations include the sample’s demographic homogeneity, predominantly White, non-Hispanic participants, which may limit generalizability to more diverse populations.
Conclusion
Lethal means safety counseling in the emergency department is vital for suicide prevention among at-risk adolescents, providing both practical risk mitigation and emotional support. Teens and caregivers value counseling that is compassionate, clear, technologically supported, and adaptable to diverse family circumstances. Challenges remain in balancing teen autonomy with safety and addressing diverse family dynamics. The study’s insights will inform the development of a brief, family-centered lethal means safety counseling intervention tailored for the ED setting, aiming to enhance uptake, efficacy, and ultimately reduce adolescent suicide risk.
Funding and Clinical Trials
Information on funding sources and clinical trial registration was not provided in the source document.
References
1. Betz ME, Barber C, Miller M, et al. Firearm access and adolescent suicide risk: a systematic review. JAMA Pediatr. 2021;175(12):1223-1231.
2. National Institute of Mental Health. Emergency Department Suicide Risk Screening Pathway. Bethesda, MD: NIMH; 2023.
3. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166(12):1170-1176.
4. Stanley B, Brown G. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256-264.
5. Gould MS, Kalafat J, Harris Munfakh J, Kleinman M. An evaluation of crisis hotline outcomes. Part 2: suicidal callers. Suicide Life Threat Behav. 2007;37(3):338-352.