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Emergency Department Suicide Screening Tool Accurately Predicts At Risk Youth

Science Update

A set of four questions that takes emergency department nurses or physicians less than 2 minutes to administer can successfully identify youth at risk for attempting suicide, reported a study by National Institute of Mental Health (NIMH) researchers that was published in the December 2012 issue of the Archives of Pediatrics and Adolescent Medicine.


boy and doctor sitting at desk

Each year as many as 5 to 8 percent of U.S. children and young adults attempt suicide, according to the U.S. Centers for Disease Control and Prevention. In 2010, 4867 youths between ages 10 and 24 died by suicide, making it the second leading cause of death for people in this age group.

Most individuals who die by suicide have visited a health care provider 3 months to 1 year before their death. Typically these patients saw an emergency department (ED) nurse and physician for some other health concern such as abdominal pain or headaches. These at-risk individuals often go unrecognized by ED staff who either lack the time or training to properly screen patients. The Joint Commission, a leading U.S.-based nonprofit healthcare accreditation organization, and the American Academy of Pediatrics have previously recommended the creation and use of suicide screening tools for adult and pediatric patient populations. To date there are no screening instruments to assess suicide risk in children and adolescents who visit EDs for medical or surgical reasons.

“Many families use the emergency department as their sole contact in the healthcare system,” said Lisa M. Horowitz, Ph.D., M.P.H., lead author of the study. “Most people don’t show up to the emergency department and say ‘I want to kill myself.’ Rather they show up with physical complaints and do not discuss their suicidal thoughts. But studies have shown that if you ask directly, the majority will tell you. Nurses and physicians need to know what questions to ask.”

Horowitz, a clinician and researcher with NIMH, and her colleagues developed a quick questionnaire that ED nurses and physicians could use to assess suicide risk among youth. Their study tested 17 candidate questions in 524 patients ages 10 to 21 years who visited one of three academically-affiliated pediatric EDs and had either psychiatric problems—suicidal ideation, intense anxiety, post-traumatic stress disorder—or medical/surgical concerns—gastrointestinal diseases, sickle cell anemia, cystic fibrosis. The questions—focusing on suicidal thoughts and behavior—were reviewed and revised by a panel of mental health clinicians, health services researchers, and survey specialists. The patients also completed one of two versions of the Suicidal Ideation Questionnaire (SIQ), the “gold standard,” 30-question suicide-screening tool that is used by pediatric and adolescent psychiatrists, but which is too long for ED visits and requires additional training. As part of the study’s safety plan, individuals whose responses indicated that they were at risk for attempting suicide were referred to mental health professionals—social workers, psychiatrists, psychologists—for further evaluation.

Results of the Study

Of the 17 candidate questions, four (used as a set) stood out as having the most accuracy for predicting suicide attempts: current thoughts of being better off dead, current wish to die, current suicidal ideation, and history of suicide attempt. Positive responses to 1 or more of these 4 questions identified 97% of the youth at risk for suicide, regardless of whether these patients came in for psychiatric or general medical concerns.

Based on results from the new questionnaire, 18.7% of the ED patients (98 of the 524) screened positive for suicide risk; most of whom had come to the ED with psychiatric concerns (84 of the 524). Elevated suicide risk was detected in 4.1% of the ED patients (14 of the 344) with medical/surgical concerns. Had it not been for the new screening tool, the suicide risk in these 14 patients most likely would have gone undetected.


The instrument based on these 4 questions, called the Ask Suicide-Screening Questions (ASQ), is the first time such a screen has been validated for pediatric and young adult patients evaluated in EDs for medical/surgical reasons. Although the number of these patients identified as high risk for suicide is small, the screen takes less than 2 minutes to administer. The tool is freely available and accessible online.

What’s Next

Additional research assessing the impact of suicidal screening in pediatric EDs on referral rates to mental health services and future suicidal behavior are needed. The accuracy of the ASQ among diverse demographic populations also needs examination. Additionally, a cost-benefit analysis for the screening tool is needed, as is research studying its use in other healthcare settings such as in-patient and out-patient care.


Horowitz LM, Bridge JA, Teach SJ, Ballard E, Klima J, Rosenstein DL, Wharff EA, Ginnis K, Cannon E, Joshi P, Pao M. Ask Suicide-Screening Questions (ASQ). A Brief Instrument for the Pediatric Emergency Department . Archives of Pediatrics and Adolescent Medicine. December 2012. 166(12):1170–1176.