Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments


David A. Brent, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Lisa M. Horowitz, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland.
Jacqueline Grupp-Phelan, Department of Emergency Medicine, UCSF Benioff Children's Hospitals, Oakland, California.
Jeffrey A. Bridge, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
Robert Gibbons, Department of Medicine, The University of Chicago, Chicago, Illinois.
Lauren S. Chernick, Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York.
Margaret Rea, Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California.
Mary F. Cwik, Department of International Health, Social and Behavioral Interventions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Rohit P. Shenoi, Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
Joel A. Fein, Center for Violence Prevention, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia.
E Melinda Mahabee-Gittens, Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Shilpa J. Patel, Division of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC.
Rakesh D. Mistry, Department of Pediatrics, University of Colorado School of Medicine, Aurora.
Susan Duffy, Hasbro Children's Hospital, Department of Pediatrics, Alpert Medical School at Brown University, Providence, Rhode Island.
Marlene D. Melzer-Lange, Department of Pediatrics, Medical College of Wisconsin, Milwaukee.
Alexander Rogers, Department of Emergency Medicine, University of Michigan, Ann Arbor.
Daniel M. Cohen, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio.
Allison Keller, Department of Pediatric Emergency Medicine, University of Utah and Primary Children's Hospital, Salt Lake City.
Robert W. Hickey, Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania.
Kent Page, Department of Pediatrics, University of Utah, Salt Lake City.
T Charles Casper, Department of Pediatrics, University of Utah, Salt Lake City.
Cheryl A. King, Department of Psychiatry, Michigan Medicine, Ann Arbor.

Document Type

Journal Article

Publication Date



JAMA network open








IMPORTANCE: Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool. OBJECTIVE: To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata. DESIGN, SETTING, AND PARTICIPANTS: The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023. MAIN OUTCOMES AND MEASURES: This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA. RESULTS: Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively). CONCLUSIONS AND RELEVANCE: This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.