Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department.

Importance: According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes. Objective: To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes. Design Setting and Participants: In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition). Exposure: Positive ASQ screen at baseline ED visit. Main Outcomes and Measures: The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk. Results: The complete sample was 15003 youths (7044 47.0%] male; 10209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]). Conclusions and Relevance: Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.Appeared originally in JAMA Netw Open 2019; 2:e1914070.

Exploring the relation between psychosis-like experiences and suicidal ideation, plans, and attempts among college students in the United States.

AIM: The suicide rate among college students is particularly high, with evidence that psychosis-like experiences (PLEs) put these individuals at greater risk. The current study explored whether there are differential relations between four subtypes of PLEs and three suicide outcomes. METHODS: We analysed a large sample of college students from the Fall semester cohort of the 2020 Healthy Minds Study (HMS) (weighted N = 36727). PLEs and suicide outcomes were assessed using binary variables from the World Health Organization Composite International Diagnostic Interview. RESULTS: Findings revealed that reporting any of the subtypes of PLEs was associated with greater odds of suicidal ideation (SI), a suicide plan (SP) and a suicide attempt (SA) (signficant a ORs ranging from 1.30 to 3.30). For college students who endorsed SI or a SP in the past year, experiencing delusional mood (aOR [95% CI] = 1.30 [1.02-1.65]), suspiciousness (aOR [95% CI] = 1.31 [1.00-1.71]) and hallucinatory experiences (aOR [95% CI] = 2.76 [2.05-3.71]) in their lifetime increased their odds of reporting a SA in the past year. There was also evidence of a dose-dependent relation between the number of PLEs endorsed and all three suicide outcomes. CONCLUSIONS: Certain subtypes of PLEs including delusional mood, suspiciousness and hallucinatory experiences may contribute to an elevated risk of suicide outcomes in college students. Moreover, the odds of reporting suicide outcomes were greater for individuals who endorsed a greater number of PLEs. It may be helpful to assess for indicated subtypes when determining suicide risk among college students and to be particularly mindful of those who report three or more PLEs.

Strengthening associations between psychotic like experiences and suicidal ideation and behavior across middle childhood and early adolescence.

BACKGROUND: Understanding risk factors related to suicidal ideation (SI) and suicidal behaviors (SB) in youth is important for informing prevention and intervention efforts. While it appears that psychotic-like experiences (PLEs) are strongly associated with both SI and SB at different points across the lifespan, the longitudinal nature of this relationship in middle childhood and early adolescence is understudied. METHODS: The study used the unique longitudinal Adolescent Brain Cognitive Development Study data. Mixed effects linear models examined associations between PLEs and SI and SB over time using three time points of data from ages 9-13. RESULTS: First, analyses indicated that endorsement of SI and SB increased as youth grew older for those with increased distressing PLEs. Analyses found evidence of bidirectional relationships between PLEs with SI and SB, with evidence that PLEs at baseline were associated with worsening SI and SB over time, including a transition from SI to SB (ß = 0.032, FDRp = 0.002). Exploratory analyses showed consistent evidence for strengthened associations over time for higher delusional ideation with both SI and SB (ßs > 0.04, FDRps < 0.001), and for perceptual distortions with SB (ßs = 0.046, FDRp < 0.001). When accounting for general psychopathology, for SB, the strengthened associations over time was significantly stronger for PLEs (ß = 0.053, FDRp < 0.001) compared to general psychopathology (ß = 0.022, FDRp = 0.01). CONCLUSIONS: The present study indicates both SI and SB show strengthened associations with PLEs over time, and that baseline PLEs may predict worsening of suicidality over time. The findings are important clarifications about the nature of the associations between youth-reported PLEs and suicidality over time.

A Deeper Dive Into the Relation Between Psychotic-like Experiences and Suicidal Ideation and Behaviors in Children Across the United States.

BACKGROUND AND HYPOTHESIS: Children who endorse psychotic-like experiences (PLEs) appear to be at a greater risk for suicidal ideation and behavior (SI/SB) compared to their peers who do not endorse PLEs. Despite evidence of differential relations among subtypes of PLEs and SI/SB, the research on which PLE subtypes produce the strongest associations remains mixed. Further, though there is evidence that general psychological distress may help explain the relation between PLEs and SI/SB, no research has investigated the role of distress specific to PLEs in this association. STUDY DESIGN: The present study sought to assess the associations among individual Prodromal Questionnaire-Brief Child Version (PQ-BC) items and SI/SB, as well as to explore the role of distress associated with PLEs as a mediator and/or moderator in a demographically diverse sample of children across the United States (N = 11 875). STUDY RESULTS: Results revealed that individual items of the PQ-BC may be differentially predictive of lifetime SI (ßs = 0.000-0.098) and SB (ßs=0.002-0.059), even when controlling for sociodemographic variables, internalizing symptoms, and traumatic experiences, with particularly strong associations observed among items indexing thought control, auditory hallucinations, suspiciousness, and nihilistic thinking/dissociative experiences. Item 13, nihilistic thinking/dissociative experiences, displayed the strongest effect sizes. Findings from moderation and mediation models provided evidence consistent with distress as both a partial mediator and moderator of the relation between total PLEs and individual PQ-BC items with SI and SB. CONCLUSIONS: Distress specific to PLEs may be an important modifiable risk factor to target in suicide assessment, prevention, and intervention efforts.

COVID-19 factors and self-injurious behaviors among US college students: findings from the healthy minds study 2020.

BACKGROUND: The COVID-19 pandemic has dramatically altered the way of life in the United States, which may be linked to self-injurious behaviors. METHODS: We conducted a secondary analysis of data from the Fall 2020 Cohort of the Healthy Minds Survey, a non-probability sample of students enrolled at one of 28 universities across the United States. Participants completed an online survey during the COVID-19 pandemic (September-December, 2020). RESULTS: Nearly a quarter of the sample (n = 6999) reported engaging in non-suicidal self-injury (NSSI), 12.41% (n = 3819) reported suicidal ideation, 4.98% (n = 1531) reported making a suicide plan, and 1.09% (n = 334) reported a suicide attempt over the past 12 months. When accounting for all COVID-19 factors in the same model, COVID-19 related concern, COVID-19 related discrimination, financial distress, and infection were significantly associated with NSSI, suicidal ideation, and suicide plan; caregiving was significantly associated with lower odds of engaging in non-suicidal self-injury. None of the factors were associated with suicide attempt. CONCLUSIONS: This study showed that various COVID-19 factors were related to SIB. Interventions may consider multiple dimensions of COVID-19 and their specific impacts.

Understanding Associations Between Race/Ethnicity, Experiences of Discrimination, and Psychotic-like Experiences in Middle Childhood.

OBJECTIVE: The present study aimed to examine factors that may account for race/ethnicity differences in psychotic-like experiences (PLEs) in a middle childhood sample, including evidence for experiences of discrimination as a psychosocial mediator of these differences. METHOD: In a sample of 9- to 10-year-olds (N = 10,839) from the Adolescent Brain Cognitive Development Study, we compared PLEs across racial/ethnic groups. We also examined whether experiences of discrimination indirectly linked racial/ethnic identity and PLEs and whether social support moderated this indirect association. RESULTS: Differences between racial/ethnic groups were found in the endorsement of PLEs, such that Black and Hispanic participants endorsed higher levels of PLEs compared with Asian, multiracial/multiethnic, and White participants. These differences were accounted for in part by experiences of discrimination, an indirect effect that was in turn attenuated by increased social support. CONCLUSION: This is the first study to suggest that the experience of discrimination may indirectly link the association between racial/ethnic differences and endorsement of PLEs using the Prodromal Questionnaire-Brief Child Version and additionally that social support may act as a moderator of this mediation. Results provide evidence that social inequities such as racial discrimination may contribute to increases in PLEs. These findings shed further light on the links between structural racism and mental health inequities for people in minoritized groups.

Psychosis-like experiences and resilience: A systematic and critical review of the literature.

Resilience research has documented the ability to cope with traumatic and stressful situations and/or retain functioning given certain risk factors in the context of psychosis. In this study, we conducted the first systematic review of the literature on psychosis-like experiences (PLEs) and resilience. Fifteen articles (from 11 unique study samples) from 10 countries were included in this systematic review, with a total of 11,937 unique study participants. Inclusion criteria were broad, capturing a wide range of individuals with PLEs who have not yet experienced threshold psychosis, such as individuals in the general population with elevated self-reports of PLEs, as well as clinical groups diagnosed by clinician interviews (i.e., clinical- or ultra-high-risk for psychosis [CHR or UHR]). For this review, studies needed to include research aims and empirical research related to resilience, and use an established or author-defined measure of psychological and/or social resilience. Data reporting quality was assessed with the Strengthening the Reporting of Observational Studies in Epidemiology and place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital (PROGRESS) guidelines. Study aims and measurement of key variables varied widely, and all studies were cross-sectional. In 73% of the studies, resilience was inversely associated with PLEs or psychosis risk status (e.g., CHR or UHR). Results related to specific resilience subscales were mixed. Author-defined resilience was typically related to internal/psychological resources. Future research, particularly longitudinal research involving multidimensional measurement of resilience (e.g., internal and external factors), along with well-defined theoretical models, are necessary before drawing firm conclusions on resilience and PLEs. We propose a dynamic, multifaceted, developmentally appropriate, and culturally sensitive model of resilience for future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Internalized stigma mediates the relation between psychosis-risk symptoms and subjective quality of life in a help-seeking sample.

Subjective quality of life can be compromised in individuals with psychosis-risk symptoms, with poorer quality of life being associated with worse functioning and later transition to psychosis. Individuals who experience psychosis-related symptoms also tend to endorse more internalized (or self-) mental health stigma when compared to controls, potentially contributing to delays in seeking treatment and increased duration of untreated psychosis, as well as interfering with treatment engagement and retention in those already receiving care. Despite these findings, and the growing recognition for prevention in earlier phases of psychotic illness, few studies have examined the relation between psychosis-risk symptoms, internalized stigma, and subjective quality of life in a younger, help-seeking sample. The present study examined whether internalized stigma mediates the relation between psychosis-risk symptoms and subjective quality of life in a transdiagnostic sample of youth (M age = 17.93, SD = 2.90) at clinical high-risk for psychosis (CHR), with early psychosis, or with non-psychotic disorders (N = 72). Psychosis-risk symptom severity was assessed using the Structured Interview for Psychosis-Risk Syndromes (SIPS). Internalized stigma was assessed using the Internalized Stigma of Mental Illness Inventory (ISMI), and subjective quality of life was assessed using the Youth Quality of Life Instrument - Short Form (YQOL-SF). Internalized stigma fully mediated the relation between psychosis-risk symptoms and subjective quality of life across the full sample (p < .05, f2 = 0.06). Findings suggest that internalized stigma may be an important target in efforts to improve quality of life for individuals in early stages of psychosis.

A Brief Text-Messaging Intervention for Suicidal Youths After Emergency Department Discharge.

Research has shown that the months after hospital discharge following treatment for suicidal thoughts or behaviors is a high-risk period for suicide. Moreover, the needs of a subset of youths at increased risk for suicide are not being met by community mental health providers, resulting in frequent emergency department (ED) visits. While undertaking a quality improvement effort, the authors' health care system piloted caring text messages to support youths discharged from the hospital after screening positive for suicide risk in the ED. The text-messaging intervention was feasible and acceptable, and youths reported that the messages helped reduce their suicidal thoughts and behaviors postdischarge. The results of this text-messaging intervention prompted the Maryland Department of Health to offer a similar intervention to all Marylanders.

Race Moderates the Relation between Internalized Stigma and Suicidal Thoughts and Behaviors in Youth with Psychosis-Risk Syndromes and Early Psychosis.

Suicide is a leading cause of death among youth on the psychosis spectrum. Internalized mental health stigma is one risk factor for suicide that may be particularly salient for youth with psychosis-risk syndromes and early psychosis. Among this population, Black youth may face exposure to racism-related stressors that may exacerbate the negative effects of internalized stigma. This study examined whether internalized stigma and race interact to predict suicidal thoughts and behaviors (STB) in a help-seeking sample of Black and White adolescents with psychosis-risk syndromes and early psychosis. Findings suggest that Black youth with early psychosis spectrum disorders may be particularly vulnerable to the negative effects of internalized stigma as they pertain to STB. Internalized stigma may therefore represent an important treatment target in suicide prevention efforts among this population.

Self-reported Symptoms of Anxiety Predict Positive Suicide Risk Screening in Adolescents Presenting to the Emergency Department.

OBJECTIVE: The objective of this study was to assess whether patient-reported anxiety symptoms are associated with suicide risk in pediatric emergency department (ED) patients. An additional objective was to examine differences between patients presenting for medical/surgical or psychiatric complaints. METHODS: Pediatric patients aged 10 to 21 years were recruited from 3 pediatric EDs. Participants completed self-report questionnaires assessing for suicidal ideation and behavior, in addition to questions of interest about recent feelings of unbearable anxiety and depression. Adjusted odds ratios were calculated to assess the relationship between endorsement of recent anxiety and screening positive for suicide risk. RESULTS: Data were analyzed from 522 participants, including 344 presenting with medical/surgical chief complaints and 178 presenting with psychiatric complaints. Overall, 28.9% of participants screened positive for suicide risk, 29.9% endorsed recent feelings of anxiety, and 24.3% endorsed recent feelings of depression. Patients who self-reported recent anxiety symptoms were 5 times more likely to screen positive for suicide risk (adjusted odds ratios = 5.18, 95% confidence interval = 3.06-8.76). Analysis of the 344 medical/surgical patients revealed that this subsample was also 5 times more likely to screen positive for suicide risk if they endorsed recent anxiety (adjusted odds ratios = 4.87, 95% confidence interval = 2.09-11.36). CONCLUSIONS: Self-reported suicidal ideation and feelings of unbearable anxiety are prevalent among patients presenting to pediatric EDs. Patients who self-report recent feelings of unbearable anxiety are significantly more likely to screen positive for suicide risk, regardless of whether their presenting complaint is medical/surgical or psychiatric in nature.

Predictors of internalized mental health stigma in a help-seeking sample of youth: The roles of psychosis-spectrum symptoms and family functioning.

Experiencing psychosis-spectrum symptoms is challenging to youth. Among many difficulties, internalized mental health stigma-the internalization of negative stereotypes-can lead to shame and withdrawal. The objective of this study was to better understand the correlates of internalized stigma among a clinical sample of youth with psychosis-spectrum symptoms. Participants (n = 66; 12-25 years old) were referred by community providers in Maryland, United States. Psychosis-spectrum symptoms were measured via the Structured Interview for Psychosis-Risk Syndromes (SIPS); family-functioning was measured via the Family Assessment Device. Interviewers rated participants' social/role functioning via the Global Functioning: Social and Role Scales. Internalized stigma was measured using the Internalized Stigma of Mental Illness (ISMI) total scale and subscales. The sample included 34 individuals at clinical high risk for psychosis, 16 experiencing early psychosis, and 16 help-seeking controls. Regression analyses indicated that unusual beliefs, avolition, role functioning, and lower family-functioning (caregiver-reported) were significantly associated with higher aspects of internalized stigma, controlling for other symptoms and sociodemographics. These models explained 27% of the variance (adjusted R2) in the total ISMI scale and between 15% to 49% of the variance in ISMI-subscales. Among this help-seeking sample, unusual beliefs, avolition, higher role functioning, and lower family-functioning (caregiver-reported) were associated with more internalized stigma. Pending future research with larger samples, therapeutic interventions focused on these factors and their correlates may benefit youth. Future research is needed to determine temporal precedence of these associations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Lowering the Age Limit in Suicide Risk Screening: Clinical Differences and Screening Form Predictive Ability.

Our research provides preliminary evidence that suicide risk screening is warranted in patients as young as 8-9 years old presenting to the emergency department (ED) with behavioral and mental health symptoms. The goal of this retrospective cohort study (N = 2,466 unique patient visits) was to assess the value of suicide risk screening in children younger than 10 years old who present to the ED with behavioral and mental health concerns. The Johns Hopkins Hospital pediatric ED began screening with the Ask Suicide-Screening Questions (ASQ) for patients 8-21 years old who presented with a behavioral or mental health concern in March 2013 as ED standard of care. We examined the demographic and clinical differences between younger (8-9 years old; n = 270) and older (10-21 years old; n = 2,196) youths who were screened for suicide risk with the ASQ (from March 13, 2013 through December 31, 2016). In summary, 36% of 8- and 9-year-old patients who came to the ED for behavioral and mental health concerns screened positive for suicide risk on the ASQ. The younger patients who screened positive were more likely to present with externalizing symptoms and hallucinations and less likely to present with suicidal ideation or an attempt than their older counterparts. Importantly, 71.1% of 8- to 9-year-old patients who screened positive did not present to the ED for suicidal ideation or attempt vs 50.1% (614/1,226) of patients older than age 10 years.

Sleep quality moderates the association between psychotic-like experiences and suicidal ideation among help-seeking university students.

Suicide is a leading cause of death for young adults, and college-enrolled students are at markedly high risk for suicide. Psychotic-like experiences (PLEs) and sleep difficulties are prevalent among college students and have been linked to increased suicidal ideation (SI). This cross-sectional study examined the relation between PLEs and SI, moderated by sleep quality, in a sample of 442 students at a university counseling center. The Behavioral Health Measure-43 (BHM-43) was used to evaluate mental health symptoms, including sleep quality and SI. The PRIME Screen-Revised was used to measure PLEs. Regression results indicated that higher PRIME scores statistically predicted greater SI. There was a significant interaction between PRIME and sleep quality in predicting SI. Among individuals with greater sleep difficulties, PLEs were positively, significantly associated with SI. The PRIME was not a significant predictor of SI at lower levels of sleep difficulties (i.e. better sleep quality). This interaction effect remained significant when controlling for age and the BHM-43 depression and bipolar subscales. Findings suggest that sleep difficulties may be linked to increased SI for individuals with PLEs, and better sleep may be protective. Further research is needed to explore treatment targeting PLEs and/or sleep to mitigate suicide risk among university students.

Abuse and suicide risk among college students in the United States: Findings from the 2019 Healthy Minds Study.

BACKGROUND: Suicide has increased among American youth, and remains a concern on college campuses where students have reported increasing levels of psychological distress, alcohol use, social isolation, and loneliness. Abuse is known to be a risk factor for suicide, but more research is needed to understand whether current specific types of abuse and their co-occurrence are related to current suicidal thoughts and behaviors among young adults in college. METHODS: We analyzed data from the 2019 wave of the Healthy Minds Study, a cross-sectional, web-based survey administered to undergraduate and graduate students. Using multivariable logistic regression, we examined the associations between abuse and suicidal thoughts and behaviors, adjusting for sociodemographic and mental health covariates. RESULTS: In the past 12 months, 12.56% of the sample reported suicidal ideation, 5.70% reported making a suicide plan, and 1.28% reported making a suicide attempt. Over a third of the sample reported at least one type of abuse over the past 12 months. Emotional, physical, and sexual abuse were all associated with greater odds of all suicide outcomes, adjusting for sociodemographic characteristics and mental health. Endorsing multiple types of abuses was associated with greater odds of suicide outcomes in a dose-response fashion. LIMITATIONS: Data were cross-sectional and the response rate for this survey was 16%. CONCLUSIONS: Universities can implement a multi-pronged approach that covers screening for types of abuse, initiating awareness campaigns around abuse and suicide, and training faculty and staff to make appropriate referrals. Student services must also be equipped to address students who perpetrate abuse.

Telepsychotherapy with Youth at Clinical High Risk for Psychosis: Clinical Issues and Best Practices during the COVID-19 Pandemic.

Early detection and prevention of psychosis has become an international priority. Much of this work has focused on youth presenting with attenuated symptoms of psychosis-those at Clinical High Risk for psychosis (CHR)-given their elevated probability of developing the full disorder in subsequent years. Individuals at CHR may be prone to exacerbated psychological distress during the COVID-19 pandemic and its subsequent physical isolation measures, due to heightened stress sensitivity and comorbid mental health problems. Telepsychotherapy holds promise for reaching this population, especially during the current COVID-19 outbreak. However, there are limited evidence-based guidelines or interventions for use of telepsychotherapy with this population. In this paper, we review common clinical issues for individuals at CHR and how they might be exacerbated by the COVID-19 pandemic; best practices for treatment and adaptations for telepsychotherapy for individuals at CHR; and highlight real clinical issues that we are currently experiencing in a United States-based specialized CHR clinic as we conduct telepsychotherapy via videoconferencing. We conclude with questions for those in the field to contemplate, as well as potential challenges and benefits in using telepsychotherapy with individuals at CHR and their families.

Screening for Suicide Risk Among Youths With a Psychotic Disorder in a Pediatric Emergency Department.

National Patient Safety Goal 15.01.01 requires all Joint Commission-accredited organizations to screen patients treated for behavioral health conditions for suicide risk. However, little is known about the ability of screening tools to identify suicide risk among youths with psychotic disorders. As part of this quality improvement initiative, youths in a pediatric emergency department with psychotic disorder diagnoses (N=87) were screened with the Ask Suicide-Screening Questions. Almost half (48%, N=42) screened positive. Most positive screens (62%, N=26) were not detected through treatment as usual, suggesting that systematic screening improves the detection of suicide risk among youths with psychotic disorders.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department.

Importance: According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes. Objective: To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes. Design, Setting, and Participants: In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition). Exposure: Positive ASQ screen at baseline ED visit. Main Outcomes and Measures: The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk. Results: The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]). Conclusions and Relevance: Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

Stability and Predictive Validity of the Parent-Child Sleep Interactions Scale: A Longitudinal Study Among Preschoolers.

Little research has examined the processes underlying children's persistent sleep problems and links with later psychopathology. The current study examined the stability of parent-child sleep interactions as assessed with the parent-reported Parent-Child Sleep Interactions Scale (PSIS) and examined whether sleep interactions in preschool-age children predict sleep problems and psychiatric symptoms later in childhood. Participants included 108 preschool-age children (50% female) and their parents. Parents completed the PSIS when children were 3-5 years (T1) and again when they were 6-9 years (T2). The PSIS includes three subscales-Sleep Reinforcement (reassurance of child sleep behaviors), Sleep Conflict (parent-child conflict at bedtime), Sleep Dependence (difficulty going to sleep without parent)-and a total score. Higher scores indicate more problematic bedtime interactions. Children's sleep problems and psychiatric symptoms at T1 and T2 were assessed with a clinical interview. PSIS scores were moderately stable from T1 to T2, and the factor structure of the PSIS remained relatively consistent over time. Higher total PSIS scores at T1 predicted increases in children's sleep problems at T2. Higher PSIS Sleep Conflict scores at T1 predicted increases in oppositional defiant disorder symptoms at T2. Children with more sleep problems and higher PSIS Sleep Reinforcement scores at T1 showed increases in attention deficit/hyperactivity disorder, depressive, and anxiety symptoms at T2. These findings provide evidence for the predictive validity of the PSIS and highlight the importance of early parent-child sleep interactions in the development of sleep and psychiatric symptoms in childhood. Parent-child sleep interactions may serve as a useful target for interventions.