Assessing the Validity of the Ask Suicide-Screening Questions in Black Youth.

BACKGROUND: Given the increasing rates of suicide and nonfatal suicide attempts among Black youth in the United States, it is crucial that screening tools are valid in identifying Black youth at risk of suicide. OBJECTIVE: This study assessed the validity of the Ask Suicide-Screening Questions (ASQ) among Black youth. METHODS: This analysis used pooled data from 3 ASQ validation studies of pediatric medical patients aged 10-21 years. All participants completed the ASQ and the gold standard Suicidal Ideation Questionnaire. RESULTS: Of the 1083 participants, 330 (30.5%) were non-Hispanic Black and 753 (69.5%) were non-Hispanic White. ASQ psychometric properties for Black and White participants were equivalent (sensitivity = 94% vs. 90.9%; specificity = 91.4% vs. 91.8%, respectively). CONCLUSIONS: There were no significant differences in ASQ psychometric properties between Black and White youth, indicating that the ASQ is valid for screening Black youth at risk of suicide.

Firearms Access among Pediatric Patients at Risk for Suicide.

BACKGROUND: Approximately 2,900 youth who die by suicide each year in the United States use a firearm. To inform lethal means safety counseling efforts, this study aimed to describe firearm access among youth deemed at risk for suicide in pediatric medical settings. METHODS: Youth who presented to one of four urban pediatric medical centers were screened for suicide risk and access to firearms. Suicide risk was determined by a positive screen on the Ask Suicide-Screening Questions (ASQ) tool. Firearm access was assessed via a structured questionnaire. RESULTS: This secondary analysis analyzed data from 1065 youth aged 10 to 17 years. Overall, 110 (10.3%) participants screened positive for suicide risk. Among those at risk, 28% (31/110) reported guns kept in or around their home, 8% (9/110) had access to a firearm, and 5% (6/110) reported that bullets were not stored separately from the guns. CONCLUSIONS: Over a quarter of youth at risk for suicide reported a firearm stored in or around their home. To ensure the safety of young people at risk for suicide, clinicians should assess whether youth have access to firearms and conduct lethal means safety counseling with youths, as developmentally appropriate, and their parent/caregivers.HIGHLIGHTS28% of pediatric patients deemed "at risk" for suicide in this study reported a firearm kept in or around their home.Among youth at risk for suicide, 8% reported having access to a firearm.These results add further evidence that it is important for clinicians to conduct lethal means safety counseling with patients and their families.

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.

A Comparison of Suicide Attempt Histories of Pediatric and Adult Medical Inpatients and Implications for Screening.

OBJECTIVE: A suicide attempt is the most potent predictor of future suicidal behavior, yet little is known about how to manage and respond to reports of attempt histories in hospitalized medical patients. This study aims to describe the prevalence and characteristics of pediatric and adult medical inpatients who report a past suicide attempt. METHOD: Participants were medical inpatients, aged 10-93 years, enrolled in two suicide risk screening instrument validation studies. Participants completed the Ask Suicide-Screening Questions (ASQ) and the Patient Health Questionnaire (PHQ). RESULTS: A total of 1324 medical inpatients (624 pediatric, 700 adult) completed the ASQ, with 114 participants (8.6%) reporting a past suicide attempt (51 pediatric; 63 adults). Comparing youth to adults, there was no significant difference between attempt rates (χ2=0.29, p = 0.59). Youth with a past attempt were significantly more likely to report past week suicidal ideation (OR = 28.22; 95% CI = 5.90, 135.06) and have a history of mental health care (OR = 9.11; 95% CI = 2.59-32.10), compared to those without a past attempt. Adults with a past attempt were significantly more likely to screen positive for depression, compared to those without attempt histories (OR = 5.00; 95% CI = 2.31-10.83). CONCLUSIONS: Nearly 9% of hospitalized medical patients endorsed a past suicide attempt when screened. Since adolescence is a critical time for detecting suicide risk, screening that includes past suicidal behavior may be an important means to identify youth with recent suicidal thoughts. By assessing recency of suicide attempts in adults, medical settings may optimize the effectiveness of how positive suicide risk screens are managed.HIGHLIGHTSRoughly 9% of medical patients reported a past suicide attempt when screened.Adolescence is a critical time for detecting suicide risk and intervening.Assessing past suicide attempts in adults can help with managing positive screens.

Screening Pediatric Medical Patients for Suicide Risk: Is Depression Screening Enough?

PURPOSE: Medically ill youth are at increased risk for suicide. For convenience, hospitals may screen for suicide risk using depression screening instruments, though this practice might not be adequate to detect those at risk for suicide. This study aims to determine whether depression screening can detect suicide risk in pediatric medical inpatients who screen positive on suicide-specific measures. METHODS: A convenience sample of medical inpatients ages 10-21 years were recruited as part of a larger instrument validation study. Participants completed the Ask Suicide-Screening Questions, the Suicidal Ideation Questionnaire/Suicidal Ideation Questionnaire-Junior, and the Patient Health Questionnaire-Adolescent Version (PHQ-A). Univariate and multivariate statistics were calculated to examine the relationship between screening positive for depression and suicide risk. RESULTS: The sample consisted of 600 medical inpatients (59.2% female; 55.2% white; mean age 15.2 ± 2.84 years). Of participants who screened positive for suicide risk (13.5%; 81/600), 39.5% (32/81) did not screen positive for depression, and more than half (45/81) did not endorse PHQ-A item 9, which queries for thoughts of harming oneself or being better off dead. Twenty-six participants (32%) who screened negative for depression and on PHQ-A item nine were at risk for suicide. CONCLUSIONS: In this sample, depression screening alone failed to detect nearly a third of youth at risk for suicide. Although depression and suicide risk are strongly related, a significant portion of pediatric medical inpatients at risk for suicide may pass through the healthcare system unrecognized if depression screening is used as a proxy for identifying suicide risk.

Validation of the ask suicide-screening questions (ASQ) with youth in outpatient specialty and primary care clinics.

OBJECTIVE: Validate the Ask Suicide-Screening Questions (ASQ) with youth in outpatient specialty and primary care clinics. METHOD: This is a cross sectional instrument validation study assessing the validity of the ASQ with respect to the standard criterion, Suicidal Ideation Questionnaire (SIQ/SIQ Jr.). The sample included 515 English speaking youth ages 10-21 years old from outpatient specialty and primary care clinics. ASQ sensitivity, specificity, positive and negative predictive values (PPV/NPV), positive and negative likelihood ratios, c statistic and respective receiver operating characteristic curves were assessed. RESULTS: A total of 335 outpatient specialty and 180 primary care clinic participants completed the study. In outpatient specialty clinics, the ASQ showed a sensitivity of 100.0% (95% CI: 80.5-100.0%), specificity of 91.2% (95% CI: 87.5-94.1%), and NPV of 100.0% (95% CI: 98.7-100.0). In the primary care clinic, the ASQ showed a sensitivity of 100.0% (95% CI: 59.0-100.0%), specificity of 87.9% (95% CI: 82.0-92.3%), and NPV of 100.0% (95% CI: 97.7-100.0). Forty-five (13.4%) outpatient specialty clinic participants and 28 (15.6%) primary care clinic participants screened positive for suicide risk on the ASQ. CONCLUSIONS: The ASQ is a valid screening tool for identifying youth at elevated suicide risk in outpatient clinical settings.

Validation and Feasibility of the ASQ Among Pediatric Medical and Surgical Inpatients.

OBJECTIVES: To validate the use of a brief suicide risk screening tool, the Ask Suicide-Screening Questions (ASQ) instrument, in pediatric inpatient medical and surgical settings. METHODS: Pediatric patients (10-21 years) hospitalized on inpatient medical and surgical units were recruited through convenience sampling for participation in a cross-sectional instrument validation study. The Suicidal Ideation Questionnaire was used as a standard criterion to validate the ASQ. Patient opinions about screening and parent consent to enroll in a suicide risk screening study were assessed to determine the feasibility of administering the ASQ in this venue. RESULTS: A total of 600 pediatric medical inpatients were screened. Compared with the gold standard, the ASQ had strong psychometric properties, with a sensitivity of 96.67% (95% confidence interval [CI]: 82.78 to 99.92), a specificity of 91.05% (95% CI: 88.40 to 93.27), a negative predictive value of 99.81% (95% CI: 98.93 to 99.99), and an area under curve of 0.94 (95% CI: 0.90 to 0.97). Only 3 participants (0.5%) had acute positive screen results on the ASQ, endorsing current suicidal ideation, whereas 77 participants (12.8%) screened nonacute positive, and 48 participants (8.0%) reported a past suicide attempt. CONCLUSIONS: The brief 4-item ASQ is a valid tool to detect elevated suicide risk in pediatric medical and surgical inpatients. Our findings also reveal that screening is feasible in terms of detection of suicidal thoughts and behaviors and is acceptable to parents and patients.

The Importance of Screening Preteens for Suicide Risk in the Emergency Department.

OBJECTIVES: To describe the prevalence of screening positive for suicide risk in a sample of 10- to 12-year-olds presenting to the emergency department (ED). METHODS: Patients presenting to the ED were administered a battery of measures, including the Ask Suicide-Screening Questions and the criterion-standard Suicidal Ideation Questionnaire. Answering affirmatively to any of the 4 Ask Suicide-Screening Questions and/or scoring above the Suicidal Ideation Questionnaire cutoff score was considered a positive screen result for suicide risk. RESULTS: The sample included 79 preteen patients. The overall positive screen result rate was 29.1% (23 of 79). More than half (54.1%) of patients presenting with psychiatric chief complaints screened positive for suicide risk, and 7.1% of preteens presenting with chief medical complaints screened positive. Of preteens, 17.7% (14 of 79) reported previous suicidal behavior. CONCLUSIONS: Preteens think about suicide and engage in suicidal behavior at rates that warrant further study. Notably, 7% of preteens presenting with chief medical complaints screened positive, highlighting the importance of screening all preteen patients as young as 10 years old for suicide risk in the ED.

Family-Based Crisis Intervention With Suicidal Adolescents: A Randomized Clinical Trial.

OBJECTIVE: In current practice, treatment as usual (TAU) for suicidal adolescents includes evaluation, with little or no intervention provided in the emergency department (ED), and disposition, usually to an inpatient psychiatry unit. The family-based crisis intervention (FBCI) is an emergency psychiatry intervention designed to sufficiently stabilize suicidal adolescents within a single ED visit so that they may return home safely with their families. The objective of this article is to report efficacy outcomes related to FBCI for suicidal adolescents and their families. METHODS: A total of 142 suicidal adolescents (age, 13-18 years) and their families presenting for psychiatric evaluation to a large pediatric ED were randomized to receive FBCI or TAU. Patients and caregivers completed self-report measures of suicidality, family empowerment, and satisfaction with care provided at pretest, posttest, and 3 follow-up time points over a 1-month period. RESULTS: Patients randomized to FBCI were significantly more likely to be discharged home with outpatient follow-up care compared with their TAU counterparts (P < 0.001). Families randomized to the FBCI condition reported significantly higher levels of family empowerment and client satisfaction with care at posttest compared with their TAU counterparts. Gains were maintained over the follow-up period. No completed suicides were reported during the study period in either condition. CONCLUSIONS: Family-based crisis intervention is a model of care for suicidal adolescents that may be a viable alternative to traditional ED care that involves inpatient psychiatric hospitalization.

A Pilot Study of the Acceptability and Usability of a Smartphone Application Intervention for Suicidal Adolescents and Their Parents.

Interconnectedness through technology presents both challenges and opportunities for suicide prevention and intervention with adolescents and families. The time following discharge from acute care facilities represents a critical period of suicide risk for adolescents, which could be buffered by a technological intervention they could use post-discharge. Crisis Care is a smartphone application intervention developed specifically for suicidal adolescents and their parents to use during this period of increased risk. A web-based prototype of Crisis Care was pilot tested with 20 adolescent-parent dyads. Results demonstrated acceptability and usability, suggesting the utility of technological interventions, such as Crisis Care, as an adjunct to treatment for suicidal adolescents and their parents following discharge from acute care settings.

Bullying and Suicide Risk Among Pediatric Emergency Department Patients.

OBJECTIVES: This study aimed to describe the association between recent bullying victimization and risk of suicide among pediatric emergency department (ED) patients. METHODS: Patients presenting to 1 of 3 different urban pediatric EDs with either medical/surgical or psychiatric chief complaints completed structured interviews as part of a study to develop a suicide risk screening instrument, the Ask Suicide-Screening Questions. Seventeen candidate items and the criterion reference Suicidal Ideation Questionnaire were administered to patients ages 10 to 21 years. Bullying victimization was assessed by a single candidate item ("In the past few weeks, have you been bullied or picked on so much that you felt like you couldn't stand it anymore?"). RESULTS: A total of 524 patients completed the interview (34.4% psychiatric chief complaints; 56.9% female; 50.4% white, non-Hispanic; mean [SD] age, 15.2 [2.6] years). Sixty patients (11.5%) reported recent bullying victimization, and of these, 33 (55.0%) screened positive for suicide risk on the Ask Suicide-Screening Questions or the previously validated Suicidal Ideation Questionnaire. After controlling for demographic and clinical variables, including a history of depression and drug use, the odds of screening positive for suicide risk were significantly greater in patients who reported recent bullying victimization (adjusted odds ratio, 3.19; 95% confidence interval, 1.66-6.11). After stratification by chief complaint, this association persisted for medical/surgical patients but not for psychiatric patients. CONCLUSIONS: Recent bullying victimization was associated with increased odds of screening positive for elevated suicide risk among pediatric ED patients presenting with medical/surgical complaints. Understanding this important correlate of suicide risk in pediatric ED patients may help inform ED-based suicide prevention interventions.

Self-Reported Recent Life Stressors and Risk of Suicide in Pediatric Emergency Department Patients.

Emergency departments (EDs) are important venues for detecting youth at risk for suicide. Children and adolescents who present to the ED and report a recent life stressor, such as stressors related to interpersonal relationships, may be at elevated risk for suicide. Utilizing data from three large, urban pediatric EDs, we examined the relationship between reported recent life stressors and suicide risk, as measured by the Suicidal Ideation Questionnaire. Overall, youth who reported a recent life stressor were at elevated risk of suicide [adjOR = 5.43 (95% CI, 3.18-9.26)]. Importantly, however, this finding was tempered by the fact that 20% of youth who screened positive for suicide risk did not report a stressor. Thus, while the knowledge of stressors may provide useful supplementary information to a suicide risk assessment, the presence or absence of a reported stressor is not sufficient to determine one's risk of suicide. ED clinicians are advised to include direct questions about suicidal thoughts and behaviors.

Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department.

OBJECTIVE: To develop a brief screening instrument to assess the risk for suicide in pediatric emergency department patients. DESIGN: A prospective, cross-sectional instrument-development study evaluated 17 candidate screening questions assessing suicide risk in young patients. The Suicidal Ideation Questionnaire served as the criterion standard. SETTING: Three urban, pediatric emergency departments associated with tertiary care teaching hospitals. PARTICIPANTS: A convenience sample of 524 patients aged 10 to 21 years who presented with either medical/surgical or psychiatric chief concerns to the emergency department between September 10, 2008, and January 5, 2011. MAIN EXPOSURES: Participants answered 17 candidate questions followed by the Suicidal Ideation Questionnaire. MAIN OUTCOME MEASURES: Sensitivity, specificity, predictive values, likelihood ratios, and area under the receiver operating characteristic curves of the best-fitting combinations of screening questions for detecting elevated risk for suicide. RESULTS: A total of 524 patients were screened (344 medical/surgical and 180 psychiatric). Fourteen of the medical/surgical patients (4%) and 84 of the psychiatric patients (47%) were at elevated suicide risk on the Suicidal Ideation Questionnaire. Of the 17 candidate questions, the best-fitting model comprised 4 questions assessing current thoughts of being better off dead, current wish to die, current suicidal ideation, and past suicide attempt. This model had a sensitivity of 96.9% (95% CI, 91.3-99.4), specificity of 87.6% (95% CI, 84.0-90.5), and negative predictive values of 99.7% (95% CI, 98.2-99.9) for medical/surgical patients and 96.9% (95% CI, 89.3-99.6) for psychiatric patients. CONCLUSIONS: A 4-question screening instrument, the Ask Suicide-Screening Questions (ASQ), with high sensitivity and negative predictive value, can identify the risk for suicide in patients presenting to pediatric emergency departments.

Family-based crisis intervention with suicidal adolescents in the emergency room: a pilot study.

The prevailing model of care for psychiatric patients in the emergency room (ER) is evaluation and disposition, with little or no treatment provided. This article describes the results of a pilot study of a family-based crisis intervention (FBCI) for suicidal adolescents and their families in a large, urban pediatric ER. FBCI is an intervention designed to sufficiently stabilize patients within a single ER visit so that they can return home safely with their families. Of the 100 suicidal adolescents and their families in the sample, 67 met eligibility criteria for FBCI. Demographic and clinical characteristics and disposition outcomes from the sample were compared with those obtained retrospectively from a matched comparison group (N = 150). Statistical analyses compared group inpatient admission rates and disposition outcomes. Patients in the pilot cohort were significantly less likely to be hospitalized than were those in the comparison group (36 percent versus 55 percent). Only two of the patients in the FBCI cohort were hospitalized immediately after receiving the intervention during their ER visit. FBCI with suicidal adolescents and their families during a single ER visit is feasible and safely limits the need for inpatient psychiatric hospitalization, thereby avoiding disruption of family, academic, and social activities and increasing use of less intrusive and more cost-effective psychiatric treatment.

Patients' opinions about suicide screening in a pediatric emergency department.

OBJECTIVE: Understanding how children react to suicide screening in an emergency department (ED) can inform implementation strategies. This qualitative study describes pediatric patients' opinions regarding suicide screening in that setting. METHODS: As part of a multisite instrument validation study, patients 10 to 21 years presenting with both psychiatric and nonpsychiatric complaints to an urban, tertiary care pediatric ED were recruited for suicide screening. Interviews with subjects included the question, "do you think ER nurses should ask kids about suicide/thoughts about hurting themselves...why/why not?" Responses were transcribed verbatim and uploaded into NVivo8.0 qualitative software for coding and content analysis. RESULTS: Of the 156 patients who participated in the study, 106 (68%) presented to the ED with nonpsychiatric complaints and 50 (32%) presented with psychiatric complaints. The patients' mean (SD) age was 14.6 (2.8) years (range, 10-21 years), and 56% of the sample was female. All patients answered the question of interest, and 149 (96%) of 156 patients supported the idea that nurses should ask youth about suicide in the ED. The 5 most frequently endorsed themes were as follows: (1) identification of youth at risk (31/156, 20%), (2) a desire to feel known and understood by clinicians (31/156, 20%), (3) connection of youth with help and resources (28/156, 18%), (4) prevention of suicidal behavior (25/156, 16%), and (5) lack of other individuals to speak with about these issues (19/156, 12%). CONCLUSIONS: Pediatric patients in the ED support suicide screening after being asked a number of suicide-related questions. Further work should evaluate the impact of suicide screening on referral practices and link screening efforts with evidence-based interventions.

Predictors of psychiatric boarding in the pediatric emergency department: implications for emergency care.

OBJECTIVES: Patients who present to the emergency department (ED) and require psychiatric hospitalization may wait in the ED or be admitted to a medical service because there are no available inpatient psychiatric beds. These patients are psychiatric "boarders." This study describes the extent of the boarder problem in a large, urban pediatric ED, compares characteristics of psychiatrically hospitalized patients with boarders, and compares predictors of boarding in 2 ED patient cohorts. METHODS: A retrospective cohort study was conducted in 2007-2008. The main outcome measure was placement into a psychiatric facility or boarding. Predictors of boarding in the present analysis were compared with predictors from a similar study conducted in the same ED in 1999-2000. RESULTS: Of 461 ED patient encounters requiring psychiatric admission, 157 (34.1%) boarded. Mean and median boarding duration for the sample were 22.7(SD, 8.08) and 21.18 hours, respectively. Univariate generalized estimating equations demonstrated increased boarding odds for patients carrying Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of autism, mental retardation, and/or developmental delay (P = 0.01), presenting during the weekend (P = 0.03) or presenting during months without school vacation (P = 0.02). Suicidal ideation (SI) significantly predicted boarding status, with increased likelihood of boarding for severe SI (P = 0.02). Age, race, insurance status, and homicidal ideation did not significantly predict boarding in the 2007-2008 patient cohort, although they did in the earlier study. Systemic factors and SI predicted boarding status in both cohorts. CONCLUSIONS: Suicidal patients continue to board. Limits within the system, including timing of ED presentation and a dearth of specialized services, still exist, elevating the risk of boarding for some populations. Implications for pediatric ED psychiatric care delivery are discussed.