The Silence Between the Questions: Reflections on Adolescent Suicide Risk When Intent Is Unclear

TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From The Clinic: The Art of Psychiatry, we evaluate psychiatric care for adolescents following injury. Working with adolescents in psychiatry can be difficult and complex, especially after injuries. Teenagers may struggle to explain their emotions or may deny distress even after dangerous events, claiming they are fine. The case example tells the story of a teenage girl who survives a firearm injury, but denies self-harm. Her denial raises difficult questions about safety and suicide risk, highlighting a challenge in child and adolescent psychiatry: assessing risk when intent is unclear.

It can be difficult to assess suicide risk in adolescents when they deny any intent. Words alone may not show the full situation. A young person’s behavior, life situation, and access to dangerous means can give a clearer picture. This is shared as a teaching reflection to support careful thinking, safety planning, and kind, thoughtful care when the full truth is not clear.

Case Example

“Veronica,” a 17-year-old girl, is admitted to the emergency department (ED) for injuries sustained during an event involving a firearm in her home. No one else was seriously injured and she claims the gun going off was merely “an accident,” but the situation raised concerns about her safety. When asked, she denies any suicidal intent.

You, as her mental health clinician, notice she is very quiet. She sits near the window and pulls the sleeves of her sweatshirt over her hands. She is hesitant to make eye contact and answers questions with shrugs or 1-word responses. When asked how she is feeling, she responds “fine.” Again, when questioned, she denies any intent to self-harm or attempt suicide. She does admit that she has easy access to her father’s gun cabinet, which he often forgets to lock.

Over the next few days, she reveals more information. School had become difficult for her. Classmates mocked her online. Rumors about her spread through social media. Friends she trusted no longer spoke to her. At home, arguments became more common and increasingly physically violent.

During the next evaluation, her sister mentions Veronica’s troubling internet search history: “Easiest way to die,” “Ways people kill themselves,” and “How long does it take to bleed out?”

When questioned about these searches, Veronica claims it was purely out of curiosity, but asks, “Can someone be falling apart without anyone noticing?” When you answer in the affirmative, she starts crying, but again claims she is “fine.” You recommend she gets psychiatric care outside of the ED and offer a referral.

Upon discharge the next day, Veronica speaks more than when she arrived. She attends groups, makes plans for follow-up care, and talks about things she wants to do in the future.

Background

Suicide is the leading cause of death among adolescents, and firearms are involved in about 65% of deaths among adolescents.^1-3 Although unintentional firearm injuries are less common, they still cause approximately 440 deaths among children in a single year, with ED visits for nonfatal injuries occurring about 5 times more often than fatal cases.¹ Firearms are the most lethal method of self-harm in adolescents, accounting for nearly 59% of suicide deaths from 2010 to 2019, with about 91% of attempts resulting in death.^1,4 By 2019, firearms were used in about 51% of suicide deaths among teenage boys and 25% among teenage girls.⁴ Although firearm suicide remains more common in boys, rates among girls have increased in recent years.^4,5 From 2019 to 2023, gun suicide rates rose by 65% among Black adolescent girls and by 25% among Hispanic adolescent girls, highlighting a growing risk in this population.⁵ Teenagers may act quickly without thinking and often find it hard to understand or explain their emotions.⁶ After serious injuries, some adolescents may say they did not mean to harm themselves, which can make it difficult for clinicians to understand the true risk.⁶

Guidance is limited for managing adolescents seriously injured by firearms who insist the event was accidental. Such cases fall between accident, impulsive behavior, and suicide attempt, showing why it is important to look beyond words. Clinicians should consider recent stress, behavior changes, emotional state, and firearm access when making decisions about adolescent safety.

Discussion

The case example shows a problem many clinicians face when working with adolescents after serious injuries. It is often hard to assess suicide risk when a teenager says they did not want to die or says the event was an accident. In situations involving firearms, uncertainty can be especially difficult because the consequences are often severe or fatal. A young person may repeatedly say, "I didn't mean it," yet the behavior itself may suggest significant risk.

Teenagers often find it hard to explain emotional pain. Some do not fully understand what they are feeling. Others may hide their distress because they feel embarrassed, scared, or worry about being judged. After a traumatic event, a young person may feel emotionally numb or show very little emotion.⁷ This may be a sign of emotional shut-down after trauma, not a sign that the person is coping well. Because of this, a calm or quiet appearance should not be taken as proof that the teen is doing well or that the risk has gone away.⁷

The case highlights several factors that may raise concerns about a teenager's safety. These include bullying, problems with friends, family conflict, feeling alone, emotional struggles, internet searches about death or suicide, and access to a firearm.⁷ None of these things by itself means that a teenager is suicidal. However, when several of these concerns are present simultaneously, the risk may be higher.⁷ Because of this, clinicians should carefully review the entire situation and conduct a thorough safety assessment.

Access to firearms needs special attention. Teenagers may act on impulse, especially when they are feeling strong emotions. Because guns are very dangerous, even a short moment of acting without thinking can lead to serious or deadly harm.⁸ For this reason, clinicians should carefully ask about access to firearms and other dangerous means. They should also talk with families about safe storage and making sure these items are kept out of reach.⁹

The case also shows that interviews alone are not always enough. Teenagers may not fully understand their own reasons or may not be able to explain them clearly. Watching behavior over time, gathering information from other sources, and using structured risk tools can give a more complete view.¹⁰ The flow chart in the Figure helps clinicians think in an organized way when intent is unclear. It looks at how serious the event was, current stress in the teen’s life, access to lethal means, and overall daily functioning. This helps guide safer planning and treatment decisions.

In the end, the goal is not to know exactly what a young person was thinking at one moment. The goal is to understand risk, reduce harm, and help create safety and recovery. It is more important to look at the whole story, not just a single statement. When clinicians do this, they are more likely to make safer and better decisions for adolescents.

Concluding Thoughts

The case in this article highlights a difficult reality in adolescent psychiatry: words do not always tell the whole story. A teenager may deny wanting to die while still engaging in behavior that places them at serious risk. Access to firearms, recent losses, trauma, and emotional distress can increase vulnerability, even when intent is unclear. Clinicians must look beyond a single statement and consider the larger picture, including behavior, life circumstances, and safety risks. Careful assessment, observation, and thoughtful safety planning can help protect adolescents during vulnerable moments and support their path toward healing and recovery.

Dr Sarker is a PGY3 psychiatry resident at Baptist Hospitals of Southeast Texas, in Beaumont, TX.

Dr Memon is a child, adolescent, and adult psychiatrist; the medical and program director of the Child & Adolescent Psychiatry Fellowship Program; and the associate program director of the Psychiatry Residency Program at Baptist Hospitals of Southeast Texas in Beaumont, TX.

References

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2. Wilson RF, Mintz S, Blair JM, et al. Unintentional firearm injury deaths among children and adolescents aged 0–17 years — National Violent Death Reporting System, United States, 2003–2021. MMWR Morb Mortal Wkly Rep. 2023;72(50):1338-1345.

3. Hink AB, Killings X, Bhatt A, et al. Adolescent suicide—understanding unique risks and opportunities for trauma centers to recognize, intervene, and prevent a leading cause of death. Curr Trauma Rep. 2022;8(2):41-53.

4. Fleegler EW. Our limited knowledge of youth suicide risk and firearm access. JAMA Netw Open. 2021;4(10):e2127965.

5. New Report Highlights U.S. 2023 Gun Deaths: Suicide by Firearm at Record Levels for Third Straight Year. Johns Hopkins University. June 26, 2025. Accessed September 15, 2026. https://publichealth.jhu.edu/2025/new-report-highlights-us-2023-gun-deaths-suicide-by-firearm-at-record-levels-for-third-straight-year

6. Lockwood J, Daley D, Townsend E, Sayal K. Impulsivity and self-harm in adolescence: a systematic review. Eur Child Adolesc Psychiatry. 2017;26(4):387-402.

7. Kılınç BB, Şener MT. Evaluation of suicide patterns, causes, and triggering factors in children and adolescents. BMC Pediatr. 2025;25(1):620.

8. Swanson SA, Eyllon M, Sheu Y, et al. Firearm access and adolescent suicide risk: toward a clearer understanding of effect size. Inj Prev. 2021;27(3):264-270.

9. Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA. 2005;293(6):707-714.

10. US Preventive Services Task Force; Mangione CM, Barry MJ, Nicholson WK, et al. Screening for depression and suicide risk in children and adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(15):1534-1542.