In Focus
Youth Suicide: 988, Suicide Exposure and Safety Planning

In Focus
Youth Suicide: 988, Suicide Exposure and Safety Planning

By Julie Cerel, PhD
University of Kentucky, College of Social Work

Youth Suicide and Risk

Suicide is the second leading cause of death for young people in the United States. Every year, almost 500 U.S. youth under the age of 15 die by suicide. That number climbs to nearly 6,000 suicides annually for youth ages 15-24. This equates to approximately one youth who dies by suicide every 1 hour and 21.8 minutes (Drapeau & McIntosh, 2024). Increases in the youth suicide rate between 2007 and 2021 were substantial, with rates for ages 10-24 increasing by more than 50% (6.8 deaths per 100,000 to 11.0 deaths per 100,000) and rates for ages 10-14 tripling during this time period (Curtin & Garnett, 2023). There are, however, some indications that the rapid increase observed during this time has leveled off (Mcintosh & Drapeau, n.d.).

Consistent with these data, research shows that suicidal ideation is common among youth with about 20% of high school students reporting they have seriously considered suicide and about 10% reporting having made an attempt (Verlenden et al., 2024). An even greater percentage of students, up to one-third, report persistent feelings of sadness.  Despite this, many youth who die by suicide are never brought to the attention of mental health professionals. In fact, in a study of more than 40,000 youth suicide decedents in the National Violent Death Reporting System, almost 60% had no documented mental health diagnosis (Chaudhary et al., 2024). Furthermore, suicide risk is not distributed equally; it is well established that suicide attempts (Verlenden et al., 2024) and deaths occur disproportionately among LGBTQIA+ youth, in youth from rural areas, and in a number of other specific demographic groups (Hua et al., 2023).

Our work shows that half of adults know someone personally who has died by suicide (Cerel et al., 2016) and that each person who dies by suicide leaves behind about 135 people who knew them personally (Cerel et al., 2019).  Notably, a large national longitudinal study (Project Lift Up; NIH # R01MH128269 PIs Mitchell & Banyard https://project-liftup.org/ ) found that almost 80 percent of 13 to 22-year-olds reported they knew at least one person who had experienced suicidal thoughts or behaviors.  The experience of knowing someone with suicidal thoughts was associated with self-reported suicidal thoughts. Moreover, the risk of personal suicidal thoughts was compounded with each additional personal contact. Specifically, youth who knew one person with suicidal thoughts were 1.75 times more likely than those without such exposure to self-report recent thoughts of suicide, those who knew between two and four people were 1.81 times more likely, and those who knew five or more people with thoughts of suicide were  3.47 times more likely to have suicidal thoughts. These findings show it is important for child psychologists to ask about peer and family suicide exposure.

988 Suicide and Crisis Lifeline

In July 2022, the 988 Suicide and Crisis Lifeline replaced the National Suicide Prevention Lifeline 1-800 number. The 988 Lifeline is made up of a network of more than 200 independent centers who answer calls, texts and chat messages, each with their own criteria for employment and/or volunteering and training. Since the inception of the 3-digit line, over 17 million contacts have been made including 12 million calls and 3 million texts (988 Lifeline Performance Metrics, 2023). While this resource is available for anyone who is in crisis or concerned about a crisis in someone they care about, there are a number of current concerns about 988 which are relevant for child clinical psychologists to consider.

Our team examined awareness of 988 and likelihood of use in a sample of 2970 adolescents and young adults ages 13 to 22 years old (Colburn, D et al., under review). Most young people were aware of 988 and many reported it was helpful because it is free and confidential. Despite this, sexual and gender minority (SGM) youth were less likely to than youth who do not identify as  SGM both to report they would use 988 and refer a friend. Participants reported a fear that 988 is not friendly to SGM young people and a concern about police or other official involvement as a result of their call. Rothman, et al., (2025), examined autistic individuals’ opinions about 988 Lifeline using the Project Lift Up data set and found some participants who had experience with 988 reported problems such as long wait times or feeling like the counselor was not able to communicate with an autistic person in an appropriate way.

Despite these perceptions, data from July 2025 shows that it took, on average, 33 seconds for a call to be answered with an average call length of 13 minutes. Texts took longer to be answered – four minutes – but had a conversation length of 55 minutes. Only four percent of 988 contacts result in what is termed “active rescue”, an in-person police or mobile crisis presence as a result of the call. In fact, half of these active rescues were a result of the caller asking for a visit due to an already in-progress suicide attempt or caller request for in-person presence (Drapeau, n.d.).

In October 2022, the 988 Lifeline initiated a “press 3” option that gave LGBTQIA+ youth, by pressing #3 at the start of their call, access to call takers with training on issues relevant to LGBTQIA+ youth. According to CNN, the “press 3” line received 1.6 million calls, texts, or online chats since its creation (The National Suicide Hotline for LGBTQ+ Youth Shut down. States Are Scrambling to Help | CNN, n.d.). On July 17, 2025, the “press 3” option for lifeline was eliminated. With the elimination of this option, all contacts are instead routed to the closest crisis center, which may or may not result in youth talking to a call taker with specialized training for LGBTQIA+ youth.  Given the concerns about 988 found in our work, it is important to think about other individual or upstream interventions that could help suicidal youth who identify as LGBTQIA+ in addition to the continued recommendation of the 988 Lifeline.                   

How to Help Someone at Risk of Suicide: Safety Planning

Safety planning interventions such as Stanley & Brown (Stanley & Brown, 2012) are widely utilized for people who have been suicidal or are in crisis. Of note, safety planning is different from no-suicide contracts which are discouraged as they do not decrease risk. Safety planning interventions involve recognizing warning signs, identifying usual coping strategies, and identifying resources to use in a future crisis (Drapeau, 2019). While these interventions have empirical support for adults, there is less data on usage of safety planning interventions with youth (Ferguson et al., 2022). In addition, there is growing evidence that psychiatric hospitalization is associated with repeat attempts in youth and often does not decrease risk of suicide death (Safer, 2021). Upstream approaches like gatekeeper training appear to be useful in decreasing youth suicide rates (Walrath et al., 2015). Thus, there is a need for research to determine both clinical approaches as well as upstream approaches to address youth suicide. 

A new approach from our team, CODE RED (Cerel et al., 2024), shifts the focus to universal prevention prior to when a crisis arises. We discuss this as planning for a “worst day” before it happens. CODE RED is intended to be implemented proactively and universally, rather than reactively and individually. Initial research with 201 school personnel (Cerel et al., 2024) and 541 youth (Cerel, et al., in submission) demonstrated that participants found CODE RED to be highly acceptable, appropriate, and feasible. At the end of completing their safety plans, over sixty percent of youth stated they had 988 in their phones.

Conclusion

Child psychologists need to be aware that suicide and suicidal behavior is a significant concern for youth. Exposure to suicidal behavior is a risk factor for personal suicidal thoughts and behaviors so clinicians should screen suicide in peer networks and not just families. The 988 Lifeline should be widely promoted as it is free and available. However, there is some concern for specific groups such as LGBTQIA+ youth as well as the loss of funding for the specific press 3 option. Clinical safety planning is an important clinical skill for clinicians working with youth who are at risk of suicide or who have made an attempt. Universal safety planning, a new approach, shows promise for everyone to have a safety plan before they become suicidal.

References

988 Lifeline Performance Metrics. (2023, February 16). https://www.samhsa.gov/mental-health/988/performance-metrics

Cerel, J., Brown, M. M., Maple, M., Singleton, M., Venne, J. van de, Moore, M., & Flaherty, C. (2019). How many people are exposed to suicide? Not six. Suicide and Life-Threatening Behavior, 49(2), 529–534. https://doi.org/10.1111/sltb.12450

Cerel, J., Fruhbauerova, M., Edwards, A., Murphy, L., Salt, E., Whipple, B., Clark, P. M., & Ackerman, J. (2024). Universal Safety Planning for Suicide Prevention: CODE RED Initial Feasibility and Acceptability. International Journal of Environmental Research and Public Health, 21(12), Article 12. https://doi.org/10.3390/ijerph21121704

Cerel, J., Maple, M., van de Venne, J., Moore, M., Flaherty, C., & Brown, M. (2016). Exposure to Suicide in the Community: Prevalence and Correlates in One U.S. State. Public Health Reports, 131(1), 100–107. https://doi.org/10.1177/003335491613100116

Cerel, J., Murphy, L., Edwards, A., & Fruhbauerova, M. (in submission). Youth Universal Safety Planning for Suicide Prevention: CODE RED Feasibility and Acceptability. School.

Chaudhary, S., Hoffmann, J. A., Pulcini, C. D., Zamani, M., Hall, M., Jeffries, K. N., Myers, R., Fein, J., Zima, B. T., Ehrlich, P. F., Alpern, E. R., Hargarten, S., Sheehan, K. M., Fleegler, E. W., Goyal, M. K., & Children’s Hospital Association Research in Gun Related Events (CHARGE) Collaborative. (2024). Youth Suicide and Preceding Mental Health Diagnosis. JAMA Network Open, 7(7), e2423996. https://doi.org/10.1001/jamanetworkopen.2024.23996

Colburn, D, Mitchell, K. J., Banyard, V., & Cerel, J. (under review). Disparities in the  Awareness and Use of the 988 Suicide & Crisis Lifeline by Sexual and Gender Identity.

Curtin, S., & Garnett, M. (2023). Suicide and Homicide Death Rates Among Youth and Young Adults Aged 10–24: United States, 2001–2021. National Center for Health Statistics (U.S.). https://doi.org/10.15620/cdc:128423

Drapeau, C. W. (n.d.). What Happens When People are Actively Suicidal? An in-depth Analysis of 988 Suicide & Crisis Lifeline Imminent Risk Data.

Drapeau, C. W. (2019). Establishing a research agenda for child and adolescent safety planning. Children’s Health Care, 48(4), 428–443. https://doi.org/10.1080/02739615.2019.1630281

Drapeau, C. W., & McIntosh, J. L. (2024). U.S.A. suicide: 2023 Official final data. Washington, DC: National Council for Suicide Prevention (NCSP), dated January 14, 2025, downloaded from [https://www.thencsp.org/suicide- statistics|. https://www.save.org/wp-content/uploads/2025/02/2023datapgsv1a.pdf

Ferguson, M., Rhodes, K., Loughhead, M., McIntyre, H., & Procter, N. (2022). The Effectiveness of the Safety Planning Intervention for Adults Experiencing Suicide-Related Distress: A Systematic Review. Archives of Suicide Research, 26(3), 1022–1045. https://doi.org/10.1080/13811118.2021.1915217

Hua, L. L., Lee, J., Rahmandar, M. H., Sigel, E. J., COMMITTEE ON ADOLESCENCE, & COUNCIL ON INJURY, V., AND POISON PREVENTION. (2023). Suicide and Suicide Risk in Adolescents. Pediatrics, 153(1), e2023064800. https://doi.org/10.1542/peds.2023-064800

Mitchell, K. J., Banyard, V., Ybarra, M. L., Jones, L. M., Colburn, D., Cerel, J., & Dunsiger, S. (2025). Understanding Contagion of Suicidal Ideation: The Importance of Taking Into Account Social and Structural Determinants of Health. Mental Health Science, 3(3), e70029. https://doi.org/10.1002/mhs2.70029

Safer, D. J. (2021). A Critique on Psychiatric Inpatient Admissions for Suicidality in Youth. The Journal of Nervous and Mental Disease, 209(7), 467. https://doi.org/10.1097/NMD.0000000000001335

Stanley, B., & Brown, G. K. (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi.org/10.1016/j.cbpra.2011.01.001

The National Suicide Hotline for LGBTQ+ youth shut down. States are scrambling to help | CNN. (n.d.). Retrieved September 17, 2025, from https://www.cnn.com/2025/08/21/health/988-lgbtq-suicide-hotline-states-kff

Verlenden, J. V., Fodeman, A., Wilkins, N., Jones, S. E., Moore, S., Cornett, K., Sims, V., Saelee, R., & Brener, N. D. (2024). Mental Health and Suicide Risk Among High School Students and Protective Factors—Youth Risk Behavior Survey, United States, 2023. MMWR Supplements, 73(4), 79–86. https://doi.org/10.15585/mmwr.su7304a9

Walrath, C., Garraza, L. G., Reid, H., Goldston, D. B., & McKeon, R. (2015). Impact of the Garrett Lee Smith Youth Suicide Prevention Program on Suicide Mortality. American Journal of Public Health, 105(5), 986–993. https://doi.org/10.2105/AJPH.2014.302496