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Ask Suicide-Screening Questions (ASQ) Toolkit

Overview

The Ask Suicide-Screening Questions (ASQ) Toolkit is a free resource for medical settings (emergency department, inpatient medical/surgical units, outpatient clinics/primary care) that can help nurses or physicians successfully identify youth at risk for suicide. The ASQ is a set of four screening questions that takes 20 seconds to administer. In an NIMH study, a “yes” response to one or more of the four questions identified 97% of youth (aged 10 to 21 years) at risk for suicide. By enabling early identification and assessment of young patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention.

Background

Suicide is a global public health problem and the second leading cause of death for young people ages 10-24 worldwide. Suicide is also a major public health concern in the United States. According to the Centers for Disease Control and Prevention (CDC), more than 5,900 youths killed themselves in 2015. Even more common than death by suicide are suicide attempts and suicidal thoughts.

Screening for Suicide Risk

Early detection is a critical prevention strategy. The majority of people who die by suicide visit a healthcare provider within months before their death. This represents a tremendous opportunity to identify those at risk and connect them with mental health resources. Yet, most healthcare settings do not screen for suicide risk. In February 2016, the Joint Commission, the accrediting organization for health care programs in hospitals throughout the United States, issued a Sentinel Event Alert recommending that all medical patients in all medical settings (inpatient hospital units, outpatient practices, emergency departments) be screened for suicide risk. Using valid suicide risk screening tools that have been tested in the medical setting and with youth, will help clinicians accurately detect who is at risk and who needs further intervention.

About the Tool

Beginning in 2008, NIMH led a multisite study to develop and validate a suicide risk screening tool for youth in the medical setting called the Ask Suicide-Screening Questions (ASQ). The ASQ consists of four yes/no questions and takes only 20 seconds to administer. Screening identifies individuals that require further mental health/suicide safety assessment.

For medical settings, one of the biggest barriers to screening is how to effectively and efficiently manage the patients that screen positive. Prior to screening for suicide risk, each setting will need to have a plan in place to manage patients that screen positive. The ASQ Toolkit was developed to assist with this management plan and to aid implementation of suicide risk screening and provide tools for the management of patients who are found to be at risk.

Using the Toolkit

The Ask Suicide-Screening Questions (ASQ) toolkit is designed for screening youth ages 10-24 (for patients with mental health chief complaints, consider screening below age 10). The ASQ is free of charge and available in multiple languages, including Spanish, Portuguese, French, Arabic, Dutch, Hebrew, Mandarin, and Korean.

It is recommended that screening be conducted without the parent/guardian present. Refer to the nursing script for guidance on requesting that the parent/guardian leave the room during screening. If the parent/guardian refuses to leave or the child insists that they stay, conduct the screening with the parent/guardian present.

What happens if patients screen positive?

Patients who screen positive for suicide risk on the ASQ should receive a brief suicide safety assessment (BSSA) conducted by a trained clinician (e.g., social worker, nurse practitioner, physician assistant, physician, or other mental health clinicians) to determine if a more comprehensive mental health evaluation is needed. The BSSA should be brief and guides what happens next in each setting. Any patient that screens positive, regardless of disposition, should be given the Patient Resource List.

The ASQ toolkit is organized by the medical setting in which it will be used: emergency department, inpatient medical/surgical unit, and outpatient primary care and specialty clinics. For questions regarding toolkit materials or implementing suicide risk screening, please contact: Lisa Horowitz, PhD, MPH at horowitzl@mail.nih.gov or Debbie Snyder, MSW at DeborahSnyder@mail.nih.gov.

Emergency Department (ED/ER):

Inpatient Medical/Surgical Unit:

Outpatient Primary Care/Specialty Clinics:

*Note: The following materials remain the same across all medical settings. These materials can be used in other settings with youth (e.g. school nursing office, juvenile detention centers).

Suicide Prevention Resources

National Suicide Prevention Lifeline
1-800-273-TALK (8255)
Spanish/Español: 1-888-628-9454

Crisis Text Line
Text HOME to 741-741

Suicide Prevention Resource Center

National Institute of Mental Health

Substance Abuse and Mental Health Services Administration

References

Horowitz, L., Ballard, E., Teach, S. J., Bosk, A., Rosenstein, D. L., Joshi, P., & Dalton, M. E. (2010). Feasibility of screening patients with nonpsychiatric complaints for suicide risk in a pediatric emergency department: a good time to talk?. Pediatric emergency care, 26(11), 787.

Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., ... & Joshi, P. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of pediatrics & adolescent medicine, 166(12), 1170-1176.

Ballard, E. D., Bosk, A., Snyder, D., Bridge, J. A., Wharff, E. A., Teach, S. J., & Horowitz, L. (2012). Patients’ opinions about suicide screening in a pediatric emergency department. Pediatric emergency care, 28(1), 34.

Horowitz, L. M., Bridge, J. A., Pao, M., & Boudreaux, E. D. (2014). Screening youth for suicide risk in medical settings: time to ask questions. American journal of preventive medicine, 47(3), S170-S175.

Ross, A. M., White, E., Powell, D., Nelson, S., Horowitz, L., & Wharff, E. (2016). To ask or not to ask? Opinions of pediatric medical inpatients about suicide risk screening in the hospital. The Journal of pediatrics, 170, 295-300.

Ballard, E. D., Cwik, M., Van Eck, K., Goldstein, M., Alfes, C., Wilson, M. E., ... & Wilcox, H. C. (2017). Identification of at-risk youth by suicide screening in a pediatric emergency department. Prevention science, 18(2), 174-182.

Newton, A. S., Soleimani, A., Kirkland, S. W., & Gokiert, R. J. (2017). A systematic review of instruments to identify mental health and substance use problems among children in the emergency department. Academic Emergency Medicine, 24(5), 552-568.