Suicidal Prediction Among Adolescents Seen in Emergency Departments Improving

Adolescent patients presenting to the ED are more likely at risk for suicide than the general population.

Universal screening of US adolescents in emergency departments (EDs) for suicidal risk is appropriate with both the Ask Suicide-Screening Questions (ASQ) instrument and the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument with strong predictive validity and similar sensitivity and specificity, according to study findings published in the Journal of the American Medical Association Network Open.

A significant increase in suicide, suicidal attempts (SAs), and rates of suicidal ideation in      adolescents have been observed in the past 15 years with significant increases among Hispanic and Black youths. About 20% of adolescents visit an ED annually, and patients presenting to the ED are more likely at risk for suicide than the general population.

Researchers sought to compare the ASQ instrument (4-item questionnaire surveying suicidal ideation and lifetime suicide attempts [SAs]) with the CASSY instrument (computerized adaptive screening tool that includes 3 ASQ items and a mean of 8 additional items) for the predictive validity of suicidal behavior among adolescents treated in EDs. The primary endpoint was suicide attempt. The secondary endpoint was suicide-related visits to the hospital or ED within 3 months of baseline.

They conducted the Emergency Department Study for Teens at Risk for Suicide, a multicenter, random-series, prospective cohort study. Adolescents who presented to 1 of 14 pediatric EDs in the Pediatric Emergency Care Applied Research Network or the Whiteriver Indian Hospital ED from July 2017 through October 2018 were recruited, oversampled by design for those with psychiatric symptoms (40.3%), then followed for 3 months to assess occurrence of suicidal behavior.

This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs.

Baseline assessments were completed by adolescents on a computer tablet in the ED. Assessment interviewers were blinded to baseline data and conducted the 3-month computer assisted follow-up by telephone. Participants received $15 at baseline and $25 or $35 at each follow-up (incentive increased from $25 to $35 for nonresponders). There were 40.9% of participants’ families receiving public assistance, and 28.9% had a previous SA.

Among available adolescents (6513), 4050 were enrolled, 3965 completed baseline assessments, and 2740 completed both screenings and follow-ups (62.2% girls; mean age at enrollment, 15.0±1.7 years; 17.1% Black, 59.1% White, 3.8% American Indian or Alaska native, 2.3% Asian or Pacific Islander, 5.9% multiracial, 11.9% unknown; 24.7% Hispanic). There was a higher likelihood of Black adolescents not being retained, as well as those who presented with a psychiatric symptom, lived in households receiving public assistance, and had parents with lower levels of education.

Among the 2740 participants, 234 (8.5%) had an SA, a suicide-related event (SRE), or both.

Researchers found ASQ and CASSY showed similar positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165] and similar negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). ASQ and CASSY showed similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]) and specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662], respectively).

Among patients with physical symptoms, the area under the receiver operating characteristic curve (AUROC) findings were similar (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). CASSY performed better than ASQ among patients with psychiatric symptoms (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively).

CASSY’s AUROC vs ASQ was significantly higher for predicting SAs (0.867 [95% CI, 0.845-0.888] vs 0.769 [95% CI, 0.750-0.789]; P <.001) and SREs (0.841 [95% CI, 0.818-0.864] vs 0.754 [95% CI, 0.732-0.777]; P <.001), respectively. They noted that the AUROCs for CASSY and for ASQ were significantly higher than those obtained by predicting future SAs based on sex, race, age, or ethnicity.

Study limitations include recruitment primarily from academic medical centers, and greater attrition among patients presenting with psychiatric symptoms, Black patients, and those whose parents were poorer and had less education.      

“This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs,” researchers concluded. They wrote “The CASSY performed better than the ASQ in predicting future SAs among patients with psychiatric concerns, who constitute a relatively small but consequential and growing proportion of pediatric ED attendees.” Similarities in predictive measures suggest both instruments perform well for universal screening in EDs.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Brent DA, Horowitz LM, Grupp-Phelan J, et al. Pediatric Emergency Care Applied Research Network (PECARN). Prediction of suicide attempts and suicide-related events among adolescents seen in emergency departments. JAMA Netw Open. Published online February 15, 2023. doi:10.1001/jamanetworkopen.2022.55986