Objective To develop a brief screening instrument to assess risk of suicide in pediatric emergency department (ED) patients. Design A prospective, cross-sectional instrument development study which evaluated 17 candidate screening questions assessing suicide risk in young patients. The Suicidal Ideation Questionnaire (SIQ) served as criterion standard. Setting Three urban, pediatric EDs associated with tertiary care teaching hospitals. Patients/Participants A convenience sample of 524 patients aged 10–21 years who presented with either medical/surgical or psychiatric chief complaints to the ED between September 2008–December 2010. Main Exposure Participants answered 17 candidate questions followed by the SIQ. 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 of suicide. Results 524 patients were screened (344 medical/surgical and 180 psychiatric). Fourteen (4%) of the medical/surgical patients and 84 (47%) of the psychiatric patients were at elevated suicide risk on the SIQ. Of the 17 candidate questions, the best-fitting model was comprised of 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 a negative predictive value (NPV) of 99.7% (95% CI, 98.2%–99.9%) for medical/surgical patients; 96.9% (95% CI, 89.3%–99.6%) for psychiatric patients. Conclusions A four-question screening instrument, the Ask Suicide-Screening Questions (ASQ), with high sensitivity and NPV, can identify risk of suicide in patients presenting to pediatric EDs.

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.

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.

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.

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.

Boarders are a problem in pediatrics, and this study identifies multiple characteristics that were associated with increasing a youth's odds of becoming a boarder at this institution. The suicidal and homicidal symptom results suggest a reverse triage system in which sicker patients are not necessarily given priority by psychiatric facilities. These data highlight mental health practices that need to be reassessed to ensure optimal care for youths with acute mental illness.

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 them-selves…why/why not?” Responses were transcribed verbatim and up-loaded 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.

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