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Identification of At-Risk Youth by Suicide Screening in a Pediatric Emergency Department

Abstract

The pediatric emergency department (ED) is a critical location for the identification of children and adolescents at risk for suicide. Screening instruments that can be easily incorporated into clinical practice in EDs to identify and intervene with patients at increased suicide risk is a promising suicide prevention strategy and patient safety objective. This study is a retrospective review of the implementation of a brief suicide screen for pediatric psychiatric ED patients as standard of care. The Ask Suicide Screening Questions (ASQ) was implemented in an urban pediatric ED for patients with psychiatric presenting complaints. Nursing compliance rates, identification of at-risk patients, and sensitivity for repeated ED visits were evaluated using medical records from 970 patients. The ASQ was implemented with a compliance rate of 79 %. Fifty-three percent of the patients who screened positive (237/448) did not present to the ED with suicide-related complaints. These identified patients were more likely to be male, African American, and have externalizing behavior diagnoses. The ASQ demonstrated a sensitivity of 93 % and specificity of 43 % to predict return ED visits with suicide-related presenting complaints within 6 months of the index visit. Brief suicide screening instruments can be incorporated into standard of care in pediatric ED settings. Such screens can identify patients who do not directly report suicide-related presenting complaints at triage and who may be at particular risk for future suicidal behavior. Results have the potential to inform suicide prevention strategies in pediatric EDs.

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References

  • Asarnow, J. R., Berk, M., Hughes, J. L., & Anderson, N. L. (2015). The SAFETY Program: a treatment-development trial of a cognitive-behavioral family treatment for adolescent suicide attempters. Journal of Clinical Child and Adolescent Psychology, 44, 194–203. doi:10.1080/15374416.2014.940624.

    Article  PubMed  Google Scholar 

  • Boudreaux, E. D., & Horowitz, L. M. (2014). Suicide risk screening and assessment: Designing instruments with dissemination in mind. American Journal of Preventative Medicine, 47, S163–S169. doi:10.1016/j.amepre.2014.06.005.

    Article  Google Scholar 

  • Breslau, N. (2009). Trauma and mental health in US inner-city populations. General Hospital Psychiatry, 31, 501–502. doi:10.1016/j.genhosppsych.2009.07.001.

    Article  PubMed  Google Scholar 

  • Bridge, J. A., Marcus, S. C., & Olfson, M. (2012). Outpatient care of young people after emergency treatment of deliberate self-harm. Journal of Child and Adolescent Psychiatry, 51, 213–222. doi:10.1016/j.jaac.2011.11.002.

    Article  Google Scholar 

  • Bridge, J. A., Asti, L., Horowitz, L. M., Greenhouse, J. B., Fontanella, C. A., Sheftall, A. H., . . . Campo, J. V. (2015). Suicide trends among elementary school-aged children in the United States from 1993 to 2012. JAMA Pediatrics, 169, 673–676. doi:10.1001/jamapediatrics.2015.0465.

  • Cappelli, M., Glennie, J. E., Cloutier, P., Kennedy, A., Vloet, M., Newton, A., . . . Gray, C. (2012). Physician management of pediatric mental health patients in the emergency department: Assessment, charting, and disposition. Pediatric Emergency Care, 28, 835–841. doi:10.1097/PEC.0b013e31826764fd.

  • Centers for Disease Control and Prevention (CDC). (2016a). 19912015 High School Youth Risk Behavior Survey Data. Retrieved from http://nccd.cdc.gov/youthonline/.

  • Centers for Disease Control and Prevention (CDC). (2016b).Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved from: http://www.cdc.gov/injury/wisqars/.

  • Folse, V. N., & Hahn, R. L. (2009). Suicide risk screening in an emergency department: Engaging staff nurses in continued testing of a brief instrument. Clinical Nursing Research, 18, 253–271. doi:10.1177/1054773809335296.

    Article  PubMed  Google Scholar 

  • Goldston, D., Molock, S., Whitbeck, L., Murakami, J., Zayas, L., & Hall, G. (2008). Cultural considerations in adolescent suicide prevention and psychosocial treatment. American Psychologist, 63, 14–31. doi:10.1037/0003-066X.63.1.14.

  • Grupp-Phelan, J., Mahajan, P., Foltin, G. L., Jacobs, E., Tunik, M., Sonnett, M., . . . Dayan, P. (2009). Referral and resource use patterns for psychiatric-related visits to pediatric emergency departments. Pediatric Emergency Care, 25, 217–220.

  • Horowitz, L. M., Wang, P. S., Koocher, G. P., Burr, B. H., Smith, M. F., Klavon, S., & Cleary, P. D. (2001). Detecting suicide risk in a pediatric emergency department: Development of a brief screening tool. Pediatrics, 107, 1133–1137.

    CAS  Article  PubMed  Google Scholar 

  • Horowitz, L. M., Ballard, E. D., & Pao, M. (2009). Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics, 21, 620–627. doi:10.1097/MOP.0b013e3283307a89.

    Article  PubMed  PubMed Central  Google Scholar 

  • Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., . . . Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of Pediatric and Adolescent Medicine, 166, 1170–1176. doi:10.1001/archpediatrics.2012.1276.

  • King, C. A., O’Mara, R. M., Hayward, C. N., & Cunningham, R. M. (2009). Adolescent suicide risk screening in the emergency department. Academic Emergency Medicine, 16, 1234–1241. doi:10.1111/j.1553-2712.2009.00500.x.

    Article  PubMed  PubMed Central  Google Scholar 

  • King, C. A., Jiang, Q., Czyz, E. K., & Kerr, D. C. (2014). Suicidal ideation of psychiatrically hospitalized adolescents has one-year predictive validity for suicide attempts in girls only. Journal of Abnormal Child Psychology, 42, 467–477.

    Article  PubMed  PubMed Central  Google Scholar 

  • King, C. A., Berona, J., Czyz, E., Horwitz, A. G., & Gipson, P. Y. (2015a). Identifying adolescents at highly elevated risk for suicidal behavior in the emergency department. Journal of Child and Adolescent Psychopharmacology, 25, 100–108. doi:10.1089/cap.2014.0049.

    Article  PubMed  PubMed Central  Google Scholar 

  • King, C. A., Gipson, P. Y., Horwitz, A. G., & Opperman, K. J. (2015b). Teen options for change: An intervention for young emergency patients who screen positive for suicide risk. Psychiatric Services, 66, 97–100. doi:10.1176/appi.ps.201300347.

    Article  PubMed  Google Scholar 

  • Knesper, D. J. (2010). Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. In American Association of Suicidology, & Suicide Prevention Resource Center. Newton: Education Development Center, Inc.

    Google Scholar 

  • Lahti, A., Harju, A., Hakko, H., Riala, K., & Rasanen, P. (2014). Suicide in children and young adolescents: a 25-year database on suicides from Northern Finland. Journal of Psychiatirc Research, 58, 123–128. doi:10.1016/j.jpsychires.2014.07.020.

    Article  Google Scholar 

  • Langhinrichsen-Rohling, J., Friend, J., & Powell, A. (2009). Adolescent suicide, gender, and culture: a rate and risk factor analysis. Aggression and Violence Behavior, 14, 402–414. doi:10.1016/j.avb.2009.06.010.

  • Larkin, G. L., & Beautrais, A. L. (2010). Emergency departments are underutilized sites for suicide prevention. Crisis, 31, 1–6. doi:10.1027/0227-5910/a000001.

    Article  PubMed  Google Scholar 

  • Ludi, E., Ballard, E. D., Greenbaum, R., Pao, M., Bridge, J., Reynolds, W., & Horowitz, L. (2012). Suicide risk in youth with intellectual disabilities: the challenges of screening. Journal of Developmental and Behavioral Pediatrics, 33, 431–440. doi:10.1097/DBP.0b013e3182599295.

    Article  PubMed  PubMed Central  Google Scholar 

  • Mahajan, P., Alpern, E. R., Grupp-Phelan, J., Chamberlain, J., Dong, L., Holubkov, R., . . PECARN. (2009). Epidemiology of psychiatric-related visits to emergency departments in a multicenter collaborative research pediatric network. Pediatric Emergency Care, 25, 715–720. doi:10.1097/PEC.0b013e3181bec82f.

  • Mann, J. J., Arango, V. A., Avenevoli, S., Brent, D. A., Champagne, F. A., Clayton, P., . . . Wenzel, A. (2009). Candidate endophenotypes for genetic studies of suicidal behavior. Biological Psychiatry, 65, 556–563. doi:10.1016/j.biopsych.2008.11.021.

  • McCann, T. V., Clark, E., McConnachie, S., & Harvey, I. (2007). Deliberate self-harm: Emergency department nurses’ attitudes, triage and care intentions. Journal of Clinical Nursing, 16, 1704–1711.

    Article  PubMed  Google Scholar 

  • Molock, S., Puri, R., Matlin, S., & Barksdale, C. (2006). Relationship between religious coping and suicidal behaviors among African American adolescents. Journal of Black Psychology, 32, 366–389.

    Article  PubMed  PubMed Central  Google Scholar 

  • Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services, 52, 828–833.

    CAS  Article  PubMed  Google Scholar 

  • National Action Alliance for Suicide Prevention Research Prioritization Task Force. (2014). A prioritized research agenda for suicide prevention: an action plan to save lives. Rockville: National Institute of Mental Health and the Research Prioritization Task Force.

    Google Scholar 

  • Pena, J. B., Matthieu, M. M., Zayas, L. H., Masyn, K. E., & Caine, E. D. (2012). Co-occurring risk behaviors among White, Black, and Hispanic US high school adolescents with suicide attempts requiring medical attention, 1999–2007: Implications for future prevention initiatives. Social Psychiatry and Psychiatric Epidemiology, 47, 29–42. doi:10.1007/s00127-010-0322-z.

    Article  PubMed  Google Scholar 

  • Reynolds, W. M. (1987). Suicidal Ideation Questionnaire (SIQ): Professional manual. Odessa: Psychological Assessment Resources.

    Google Scholar 

  • Segers, M., & Rawana, J. (2014). What do we know about suicidality in autism spectrum disorders? A systematic review. Autism Research, 7, 507–521. doi:10.1002/aur.1375.

    Article  PubMed  Google Scholar 

  • Sheridan, D. C., Spiro, D. M., Fu, R., Johnson, K. P., Sheridan, J. S., Oue, A. A., . . . Hansen, M.L. (2015). Mental health utilization in a pediatric emergency department. Pediatric Emergency Care, 31, 555–559. doi:10.1097/PEC.0000000000000343.

  • Suominen, K., Isometsa, E., Suokas, J., Haukka, J., Achte, K., & Lonnqvist, J. (2004). Completed suicide after a suicide attempt: a 37-year follow-up study. American Journal of Psychiatry, 161, 562–563.

    Article  PubMed  Google Scholar 

  • The Joint Commission. (2010). A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_46.pdf.

  • The Joint Commission. (2016). Detecting and treating suicide ideation in all settings. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf.

  • Ting, S. A., Sullivan, A. F., Boudreaux, E. D., Miller, I., & Camargo, C. A., Jr. (2012). Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993 2008. General Hospital Psychiatry, 34, 557–565. doi:10.1016/j.genhosppsych.2012.03.020.

    Article  PubMed  PubMed Central  Google Scholar 

  • Wilson, K. M., & Klein, J. D. (2000). Adolescents who use the emergency department as their usual source of care. Archives of Pediatric and Adolescent Medicine, 154, 361–365. doi:10.1001/archpedi.154.4.361.

    CAS  Article  Google Scholar 

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Correspondence to Elizabeth D. Ballard.

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Funding

This study was supported in part by an award from the Garrett Lee Smith grant U79SM061751 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Ethical Approval

The Johns Hopkins University School of Medicine Institutional Review Board approved this medical record review of data collected as standard of care. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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For this type of study, formal consent is not required.

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Ballard, E.D., Cwik, M., Van Eck, K. et al. Identification of At-Risk Youth by Suicide Screening in a Pediatric Emergency Department. Prev Sci 18, 174–182 (2017). https://doi.org/10.1007/s11121-016-0717-5

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  • DOI: https://doi.org/10.1007/s11121-016-0717-5

Keywords

  • Suicide
  • Emergency department
  • Screening
  • Pediatrics