Overall, most study participants agreed with suicide screening efforts and stated that children and adolescents should be asked about suicide in the pediatric ED. Moreover, only 35% of all participants reported that they had ever been asked about suicide in the past. When asked to elaborate further on their opinions, the participants stated beliefs that asking directly about suicidal thoughts could help identify youth at risk, address their desire to be understood, allow youth contemplating suicide to get help, aid in the prevention of suicidal behavior, and provide an unbiased listener with whom to speak. The few patients who disagreed with screening cited concerns about iatrogenic risks of suicide assessment; however, there is no evidence that asking about suicide will lead to an increase in suicidal thoughts or behavior in children or adolescents.8
Interestingly, participants were asked for their thoughts after experiencing a battery of suicide-related questions in the ED. Other research has explored adolescent beliefs in focus group discussions or other hypothetical scenarios, but this is the first study to evaluate screening in the ED after participants experienced standardized suicide screening.
One of the most commonly identified themes supported by these data was the notion that directly and specifically asking patients about suicide was important. Participants believed that if they were not specifically asked, youth would not offer up this information unsolicited. This theme relates to current research detailing that many children with depression and suicidal ideation are not identified12
and that screening efforts can detect mental health conditions in children with nonpsychiatric complaints. 13,14
Focus group discussions with community adolescents and parents also suggest that parents do not believe that they are able to identify a suicidal adolescent,15
which led the authors to conclude that systematic screening may be indicated. Overall, these responses suggest that youth who experience suicidal ideation may not volunteer this information unless specifically asked.
Beyond the identification of at-risk youth, participants also suggested that screening was a way for patients to feel known, heard, and understood. These comments suggested that these participants believed that identifying suicide risk is part of obtaining a comprehensive picture of the patient. Moreover, a few of the participants connected the screening to personal experiences of friends displaying suicidal behavior, demonstrating that adolescent suicide is not an uncommon concern in their peer groups. In contrast, in parent-adolescent focus group discussions around the country, participants identified suicide as a nationwide concern but did not believe that adolescent suicide was a problem in their own communities.15
Another identified theme was that adolescents are not being asked about suicide elsewhere. Fewer than half of the patients reported that they had been asked about suicide before this ED visit, suggesting that while screening programs are being implemented into schools and primary care settings,4
there are still many children and adolescents who are not routinely assessed. Furthermore, as for disclosing these thoughts to adults, some participants felt that they would be criticized and/or did not seem comfortable telling their parents; rather, they viewed the ED nurse as someone impartial with whom they could discuss their suicidal thoughts and feelings. These comments suggested that the ED would be a particularly optimal setting for screening efforts.
The participants also connected screening efforts with a way to provide suicide prevention and intervention strategies with teens. They believed that through screening efforts, individuals who were at-risk could receive “help” that would prevent later suicidal behavior. This connection of screening to validated interventions has been stressed as an essential component of effective suicide prevention through screening.4,16
Mental health screening in adolescent primary care settings has been shown to be associated with increased mental health services.17
However, identification of previously undetected mental health concerns in the ED in adolescents has not been shown to lead to an increase in psychiatric follow-up beyond the ED,18
suggesting that further work is needed in designing effective interventions for positive screens in the ED.
Another special consideration identified by participants included the appropriate age range for suicide screening. An analysis of suicide screening in children younger than 12 years suggests that younger children in the ED may endorse suicidal thoughts and behaviors when asked, but the validity of these responses warrant further investigation.19
Participants also raised concerns about the effects of chronic medical illness on emotional health in pediatric psychosomatic medicine literature20–22
and whether individuals should be screened according to presenting complaint, a topic currently under investigation by researchers studying suicide screening23,24
and depression screening.14
Further analyses within the larger multisite study will investigate the impact of chronic illness on suicide risk.
This study had several limitations including the fact that data were collected using a convenience sample of patients recruited from a single urban pediatric ED. Responses, therefore, may not generalize to other patient populations or settings. It should be noted that this particular ED provided full evaluations for psychiatric patients up to age 18 years only and arranged evaluations elsewhere for older patients.
In addition, participants and their parents agreed to participate in a suicide assessment study, which may have biased the patient population toward individuals who were more likely to agree that suicide screening was important. It is not known whether the 40% of patients and guardians who declined to participate would have agreed with suicide screening; however, most of the declines occurred because the parents were concerned about pressing medical concerns and chose not to participate in research. Further analysis of the decline rates is presented elsewhere. 24
Parents were not in the room during this evaluation, but participants were told that safety concerns would be shared with parents, which also may have impacted responses. Lastly, as part of the study inclusion criteria, patients who would not be able to communicate in English as well as individuals without a legal guardian in the ED (eg, foster care populations) were excluded from data collection further limiting generalizability. However, this is the first known study of individuals in the pediatric ED who were asked their opinions about suicide screening after being asked a set of suicide-related questions. It is possible that, through their own experience of being asked about suicide, participants had a new perspective on whether screening should be implemented universally.