Q&A: How to screen young patients for suicide risk

BySara Kellner

ByLisa M Horowitz, PhD, MPH

Fact checked byCarol L. DiBerardino, MLA, ELS

Key takeaways:

One in five children who died in 2022 died by suicide.
Suicide prevention starts with a brief screening, followed by a safety assessment to determine what the patient needs next.

Suicide is one of the leading causes of death among youth in the United States, and pediatricians play an integral role in identifying patients who are at risk and connecting them to resources.

One of the most effective ways to do that is through universal suicide risk screening.

IDC0125Horowitz_graphic — Derived from Horowitz LM, et al. *Gen Hosp Psychiatry.* 2018;doi:10.1016/j.genhosppsych.2018.11.009.

Lisa M. Horowitz, PhD, MPH

“Kids are not supposed to die; they are supposed to grow up and live long, healthy lives,” Lisa M. Horowitz, PhD, MPH, senior associate scientist and pediatric psychologist and director of patient safety and quality at the National Institute of Mental Health (NIMH), told Healio. “But if you look at death registry statistics for youth who died in 2022, 20% of them died by suicide. That means a staggering number died by something that is potentially preventable.”

Horowitz said pediatric practices are extremely important for identifying suicide risk early. A 2024 study reported that 60% of youth aged 10 to 24 years who died by suicide did not have a diagnosed mental illness.

“That means the majority are just passing right through our health care system,” Horowitz said. “Most people who die by suicide, including young people, have visited a health care provider not just months, but sometimes a week before they took their life.”

In 2022, the AAP recommended suicide risk screening for all children aged 12 years or older. However, because suicide rates are rising among preteens aged 8 to 12 years, Horowitz recommends screening children at age 10 years and older.

Healio spoke with Horowitz about how to implement universal screening in pediatric practices and what to do when patients screen positive. There is a list of resources for pediatricians to learn more about suicide risk screening and suicide prevention at the end of the article.

Healio: Is it feasible for pediatricians to universally screen for suicide risk?

Horowitz: When you look at the AAP Bright Futures Periodicity Table, pediatricians have to screen for so many things, but suicide is what kids are dying from. There are suicide risk screening tools, but my research team created one specifically for pediatricians — the Ask Suicide-screening Questions (ASQ) toolkit — and it takes 20 seconds.

A lot of people use a depression screen, the Patient Health Questionnaire-9, and the last question is considered a suicide risk question. But there are 13 studies that show that screening for depression is not sufficient to identify all young people at risk for suicide. We are trying to get pediatricians to add a suicide risk-specific screening tool onto their depression screens because not all kids at risk for suicide are depressed.

The most important thing to know is that the suicide risk screening tool has to be part of a clinical pathway. The first step is the brief screening, which should take 20 seconds. The second step is the most important part of the pathway, which is further triage of the screen. To do this suicide risk assessment, we created the ASQ Brief Suicide Safety Assessment, but there is also the Columbia Suicide Severity Rating Scale. The third step is determining what the patient needs next.

What I have seen from consulting for pediatric practices around the country is that there are 100 different ways to do those three steps, and the most important thing is that you nuance it so it works for your practice.

Healio: What should pediatricians do if their patient screens positive? What should their next steps be?

Horowitz: The good news is that most people who have thought about suicide are not an emergency. We don’t want everyone who has thought about suicide to be sent to the ED.

Every pediatrician should have a plan before they start screening. One thing they need is a relationship with a mental health provider who can further evaluate the kids who screen positive. But if they do not have that, there are three interventions that every pediatrician can do right away. They can do safety planning, lethal means safety counseling, and they can give every child the 988 number, which is available 24/7 by phone or text.

Every pediatrician can make a safety plan, which is generated by the patient. Ask them to identify what triggers their suicidal thoughts and then have them come up with coping strategies to keep themselves safe like listening to music, watching TV, exercise, etc..

Over half of kids’ suicides are from firearms in the house. Lethal means counseling involves figuring out how to make sure their house is safe when they are thinking about suicide.

Healio: How can pediatricians discuss suicide risk with their patients’ parents?

Horowitz: When you screen, you should ask the parents to step out. You want to say, “I am going to screen your child for suicide risk. If I have any safety concerns, I will let you know.” If the parents will not step out, it is OK to screen in front of them, because you are modeling how to talk to kids about suicide risk.

Once a child screens positive, you can say, “I have some concerns about your child’s safety, and I want to further evaluate them,” or “I want to send them to someone who can do a full mental health evaluation.”

Most parents do not know their child is thinking about suicide, not because they are bad parents or because they are not paying attention, but because kids keep these thoughts to themselves, or they share with their friends. When you are working with children and teenagers, it is really important to know how to bring the parents into the conversation.

Healio: What should physicians keep in mind when screening underserved and understudied groups of children?

Horowitz: There are understudied populations that are at higher risk for suicide, including youth of color — Black youth right now have the steepest increase in suicide, and American Indians have the highest rates of suicide compared with any other race or ethnicity. Kids who identify as LGBTQ+ are at higher risk. Kids in the child welfare system, the juvenile detention system and rural areas are all understudied populations.

Universal screening is a way to promote health equity, because if you ask everybody, then everybody has a chance of getting help. But you have to make sure the tools perform equitably in all populations.

We tested our ASQ tool with Black youth and white youth, and there were no differences in the psychometric properties of the tool and how it performed.

You also have to be culturally sensitive. For example, we are rolling out suicide risk screening in all of the Indian Health Service medical facilities, and there are some tribes that do not talk about death because they believe that it brings death. In that kind of situation, you need to change the tool so it works for them, and then you need to study the tool to make sure the changes you made are still valid.

Healio: Is insurance a barrier for screening children and directing them to resources if they screen positive?

Horowitz: I believe there is a CPT code for suicide prevention/screening, so that pediatricians can get reimbursed. But what happens more often is there is not access to mental health care, so there are those three interventions that pediatricians can do in their office.

Healio: Are there any other barriers to screening that you have seen?

Horowitz: The number one thing pediatricians worry about is time. They have a waiting room full of kids, and they are worried that this is going to derail their visits. Maybe a child comes in for a well visit to get clearance to play soccer, and you screen them for suicide risk. If they screen positive, then you have to decide if you need to postpone that visit or do both at the same time.

They also worry about positive screen rates. The rates vary depending on age, but we see them anywhere from as low as 2% to as high as 20%. It is usually somewhere around 3% to 5%. In an ED, it is a little higher. I tell pediatricians that the majority of your kids, maybe 95%, are going to screen negative — it will be 20 seconds, and screening will be done. But when you find someone who is thinking about suicide, that is an opportunity to help them.

Healio: What resources are available for pediatricians to learn more about this?

Horowitz: There is help for pediatricians. The AAP has Project ECHO (Extension for Community Healthcare Outcomes), where no matter where you live, you can call into a webinar. I was part of a team with AAP, the American Foundation for Suicide Prevention and some people from NIMH to create the Blueprint for Youth Suicide Prevention, which was made specifically for pediatricians. It has a wealth of information, including a section on health equity and being culturally responsive.