BACKGROUND To determine whether a delineation of suicide attempt severity via toxic ingestion distinguishes adolescents in terms of needs for medical and psychosocial support. METHODS Cross-sectional study performed between 1995 through 1997 in which 92 adolescents, mean age 15.6 years, presented to an urban pediatric emergency department for a nonfatal suicide attempt by ingestion. As defined by the authors, these adolescents were divided into 2 groups. The higher risk or more severe attempt group (n = 54) was defined as those that either ingested a toxic amount of a drug or had a toxic blood level or were admitted to the intensive care unit secondary to abnormal vital signs. The lower risk or less severe attempt group (n = 38) included those that did not meet these criteria. A 50-item confidential questionnaire was administered in the emergency room, which included information on demographic, clinical/laboratory, psychosocial characteristics and review of all psychiatric consultation(s). RESULTS In accord with our definition, the higher risk or more severe attempt group was more likely than the lower risk or less severe attempt group to have elevated heart rates at intake (96.4 +/- 18.4 vs. 87.0 +/- 18.0, P = 0.023), and to have ingested a drug less than 3 hours prior to the arrival to the emergency room (59% vs. 29%, P < 0.037). These individuals were more likely to have been diagnosed by the consulting psychiatrist as having an adjustment disorder (77% vs. 50%, P < 0.013), and to have fewer than 2 prior suicide attempts (100% vs. 84%, P < 0.019). There were no differences between the 2 groups with regard to family history of suicide behaviors, drug/alcohol use, type of drug ingested (analgesics being the most common), sexual activity, rape, school grade, and pregnancy. CONCLUSIONS The higher risk or more severe suicide attempt group of these urban adolescents were associated with psychologic adjustment disorder, but was not associated with other known risk factors for suicidal behaviors.