Suicide and Life-Threatening Behavior 45 (3) June 2015 © 2014 The American Association of Suicidology DOI: 10.1111/sltb.12133

345

Assessment of Suicidal Youth in the Emergency Department MICHELE S. BERK, PHD,

AND

JOAN R. ASARNOW, PHD

Accurate evaluation of suicidal adolescents in the emergency department (ED) is critical for safety and linkage to follow-up care. We examined selfreports of 181 adolescents who presented to an ED with suicidal ideation (SI) or a suicide attempt (SA). Parents also completed self-reports. Results showed fair agreement between parents and youth on the reason for the ED visit (e.g., SI vs. SA) and greater agreement between independent judges and youths than between judges and parents. In accordance with accepted definitions of suicide attempts (e.g., Crosby, Ortega, & Melanson, 2011; O’Carroll, Berman, Maris, Moscicki, Tanney, & Silverman, 1996, p. 237; Posner, Oquendo, Gould, Stanley, & Davies, 2007, p. 1035; Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007, p. 248), most youth with SA as the reason for the ED visit reported some intent to die associated with the attempt. Finally, youth presenting to the ED with SA did not differ clinically from youth presenting with SI, and almost half of youths with SI reported past suicide attempts. These results highlight the need to emphasize adolescents’ reports in clinical decision making, suggest adolescents’ defined suicide attempts similarly to published definitions, and show that assessment of past SAs, as well as present suicidal thoughts and behaviors, is critical in determining future risk.

Suicide is a significant public health problem among adolescents. In 2011, suicide was the third leading cause of death among 10- to 14-year-olds and the second leading cause of death among 15- to 24-year-olds in the United States (Centers for Disease Control & Prevention, 2011). Recent statistics from the MICHELE S. BERK, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA, and David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; JOAN R. ASARNOW, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. This research was supported by the grant CCR921708 from the Centers for Disease Control and Prevention. Address correspondence to Michele S. Berk, Department of Child and Adolescent Psychiatry, Harbor-UCLA Medical Center, 1000 W. Carson St., Box 498, Torrance, CA 90509; E-mail: [email protected]

Youth Risk Behavior Survey (YRBS), a nationally based, yearly survey of high school students in the United States, showed that 17% had seriously considered attempting suicide in the past year, 13.6% had made a plan about how they would attempt suicide, and 8% had attempted suicide one or more times (Kahn et al., 2013). The National Strategy for Suicide Prevention (2012) emphasizes the emergency department (ED) as a critical site for suicide prevention efforts, with the potential for identifying and treating youths at high risk of death by suicide. While there is general agreement regarding the importance of effectively evaluating and treating suicidal adolescents, assessment of suicide risk in the ED can be challenging. The ED clinician must incorporate information from multiple informants (e.g., adolescents, parents, outpatient treat-

346 ment providers) within a brief period of time to determine the degree of imminent danger of suicidal behavior and to decide whether the adolescent requires inpatient hospitalization or can safely be discharged home (Kennedy, Baraff, Suddath, & Asarnow, 2004). Both the adolescent and his or her caregiver may be reluctant to openly share information due to reasons such as stigma, feelings of shame and embarrassment, and the desire either to avoid hospitalization or to obtain hospitalization (Wagner, Wong, & Jobes, 2002; Wintersteen, Diamond, & Fein, 2007). Characteristics unique to the ED setting, such as long waits, a chaotic environment, brief contacts with health professionals, exposure to other severely ill patients, and lack of privacy, may also inhibit adolescents and families from disclosing sensitive information to providers (Wintersteen et al., 2007). Low agreement between parent and youth reports of youth suicidality presents another obstacle for ED clinicians. It has been shown that parents are often unaware of their adolescents’ suicidal thoughts and behaviors (see Breton, Tousignant, Bergeron, & Berthiaume, 2002; Kashani, Goddard, & Reid, 1989; Sourander, Helstel€a, & Helenius, 1999; Velez & Cohen, 1988; Walker, Moreau, & Weissman, 1990; Zimmerman & Asnis, 1991). Although research on interrater agreement within the ED setting is limited, one study conducted in the ED found moderate levels of agreement between youths’ and parents’ reports of suicidal thoughts and attempts on a questionnaire asking about the reason for the ED visit (Cloutier et al., 2010). Other work with psychiatrically hospitalized youths (Klaus, Mobilio, & King, 2009) found low rates of agreement between parents and adolescents for suicidal ideation and planning for suicide in both the past month and past year, but higher agreement for ratings of suicide attempts, with past month ratings showing good agreement and past year showing moderate agreement. Adolescents reported a greater number of suicidal thoughts, plans, and attempts overall than their parents.

ASSESSMENT

OF

SUICIDAL YOUTH

IN THE

ED

Another difficulty is determining whether the youth has made a suicide attempt versus engaged in nonsuicidal selfinjury (NSSI) behavior. Although European studies have focused more broadly on the range of self-harm behaviors (NICE, 2004; Ougrin, Tranah, Leigh, Taylor, & Asarnow, 2012), researchers in the United States have emphasized the distinction between suicide attempts and NSSI. The “intent to die” (e.g., the intent to cause one’s own death), which is central to the definition of a suicide attempt (e.g., Crosby, Ortega, & Melanson, 2011; O’Carroll, Berman, Maris, Moscicki, Tanney, & Silverman, 1996; Posner, Oquendo, Gould, Stanley, & Davies, 2007; Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007), is not an observable behavior. Hence, the clinician is dependent on the adolescent’s self-report of his or her intent to die to determine whether he or she has attempted suicide. Youth selfreports may be unreliable because adolescents may be unsure of their reasons for engaging in self-injurious behavior, as well as motivated to conceal their degree of intent to die in order to gain a desired outcome (e.g., avoid hospitalization or gain hospitalization as a potential respite from what they perceive as an unbearable situation; Wagner et al., 2002). Adolescents may also under- or overestimate the lethality of suicide methods (Harris & Myers, 1997), making it difficult to use an objective measure of lethality as an indicator of the intent to die. It has been shown that approximately half of individuals who endorsed making a suicide attempt during a structured interview had no intent to die (Nock & Kessler, 2006). As the intent to die during a suicide attempt in adults has been shown to be a predictor of subsequent suicide death (Brown, Henriques, Sosdjan, & Beck, 2004), as well as associated with increased risk factors for suicide (Nock & Kessler, 2006), distinguishing between suicide attempts and NSSI is of importance in managing safety. Another issue requiring clarification concerns whether youths presenting to the

BERK

AND

ASARNOW

ED with suicide attempts versus suicidal ideation represent distinct subgroups. Prior work has shown that psychopathology and other suicide risk factors increase as youths progress along a severity continuum from suicidal ideation to a single attempt to multiple attempts (Asarnow et al., 2008; Esposito, Spirito, Boergers, & Donaldson, 2003; Goldston, Daniel, Reboussin, & Kelley, 1996; Rosenberg et al., 2005; Stein, Apter, Ratzoni, Har-Even, & Avidan, 1998; Walrath et al., 2001), and that a history of multiple suicide attempts may be a marker for severe psychopathology and increased suicide/suicide attempt risk in both youths and adults (Asarnow et al., 2008; Forman, Berk, Henriques, Brown, & Beck, 2004). However, the extent to which the level of suicidality at the time of the ED visit (attempt vs. ideation) is associated with different patterns of psychopathology, service use, and psychosocial stress, as well as future suicidal behavior, remains to be clarified. This study is part of our research program aimed at improving care for suicidal adolescents seen in the ED. This study had three major aims. First, we examined the level of agreement among different informants about the reason for the ED visit (e.g., suicidal ideation or suicide attempt) by comparing ratings made by youth, parents, and independent judges. Consistent with prior research, we expected youth and parent agreement to be moderate at best and to be better for suicide attempts than for suicidal ideation (Cloutier et al., 2010; Klaus et al., 2009). Because youth are likely to have greater knowledge of their own thoughts and behaviors than their parents, we predicted that youth reports of suicidal ideation and attempts would be more consistent with independent judges’ (who had access to both youth and parent reports) than with parents’ ratings. Second, we examined whether, consistent with definitions of suicide attempts (e.g., Crosby et al., 2011; O’Carroll et al., 1996; Posner et al., 2007; Silverman et al., 2007), youth who were judged as coming to the ED for a suicide attempt would endorse some degree

347 of intent to die associated with the attempt. Given that we did not provide youth with a definition of a suicide attempt, this allowed clarification of the degree to which adolescents’ conceptualizations of suicide attempts were consistent with the definitions described here. Finally, we examined differences in demographics, history of suicidal behavior, psychopathology, life stressors, and prior treatment history between youth presenting to the ED with suicidal ideation versus a suicide attempt to determine whether they differed on variables that would impact ED care, disposition, and follow-up. Based on data showing that a history of prior suicide attempts is associated with more severe psychopathology (Asarnow et al., 2008; Forman et al., 2004), we expected that youth presenting to the ED for a current suicide attempt versus ideation would report more serious clinical symptoms.

METHOD

This research is part of a larger randomized clinical trial (RCT) conducted by our group that looked at a brief, familybased, cognitive-behavioral intervention for suicidal youth conducted in the ED (Asarnow, Berk, & Baraff, 2009). Because a detailed description of study methods has been published elsewhere (Asarnow et al., 2008; Asarnow, Berk, et al., 2009; Asarnow, Emslie, et al., 2009), we emphasize the measures used in this study and provide a brief overview. Participants Participants were recruited from two large EDs providing emergency mental health services in the Los Angeles area. The first ED was in a largely middle-class area, connected to a psychiatric hospital with youth inpatient services, and served roughly 42,000 patients annually. The second ED was located within a large county hospital that served about 77,000 largely disadvantaged,

348

ASSESSMENT

ethnic minority patients annually across psychiatric, adult, and pediatric EDs. All procedures were approved by the institutional review boards at each site, and all subjects gave informed assent or consent and parents gave informed consent. Participants were recruited from consecutive ED patients between November 2002 and August 2005 at the first site and between October 2003 and August 2005 at the second site. Inclusion criteria were as follows: suicidal ideation and/or a suicide attempt as the reason for the ED visit, and age 10 to 18 years. Exclusion criteria were the following: acute psychosis/symptoms that impede consent/assessment; no parent/ guardian to consent (youth < 18); youth not English-speaking; parents/guardians not English- or Spanish-speaking; and already enrolled in the study. Following a pilot phase of the study, 181 adolescents were randomized to either the intervention condition or usual care. Best estimate ratings by independent judges were conducted on the randomized sample only (for a detailed description of the sample and recruitment, see Asarnow et al., 2008; Asarnow, Baraff, et al., 2011; Asarnow, Porta, et al., 2011). Assessment Procedures Youth and parents completed a series of self-report measures and provided basic demographic data in the ED after giving informed consent/assent. Assessment measures included youth and parent selfreport questionnaires requiring 20 to 30 minutes to complete. Youth and parents completed assessments separately to ensure confidentiality. Measures Suicidality. Because of the need for brief screening measures that could be completed during the ED visit, suicidal ideation and attempts were assessed using self-report measures. Youth and parents were asked to endorse the primary reason for the ED visit from a list of choices that included: (1) car

OF

SUICIDAL YOUTH

IN THE

ED

or motor vehicle accident, (2) suicide attempt, (3) suicidal thoughts, (4) assault, (5) illness, (6) cutting, burning, or otherwise hurting yourself, (7) other injury, and (8) other. History of suicidality was examined using questions from the YRBS. Used in national surveillance, YRBS items have established psychometric adequacy (Brener et al., 2004). Youth who endorsed a suicide attempt as the reason for their ED visit were also asked to report their intent to die using a single self-report item derived from the Suicide Intent Scale (Beck, Schuyler, & Herman, 1974; Beck & Steer, 1989). Youth responded to the question, “When you tried to hurt yourself, did you want to die?” using a three-point scale (0 = no, I did not want to die, 1 = part of me wanted to die and part of me did not want to die, and 2 = yes, I wanted to die). Because definitions of suicide attempts typically require “nonzero” intent to die (e.g., Crosby et al., 2011; O’Carroll et al., 1996; Posner et al., 2007; Silverman et al., 2007), “yes” and “part of me wanted to die” were later collapsed into a single “yes” category. Because this item was added later in the study, it was administered to only 69 of the 96 (72%) youth who endorsed a suicide attempt as the reason for the ED visit. The assessment battery did not include separate items on NSSI behaviors. Psychopathology. Youth depression in the week prior to the ED visit was assessed using the CES-D, a 20-item self-report measure that asks about past-week depressive symptoms and is reliable and valid in both adolescents and adults (Clarke et al., 1995; Radloff, 1977). Youth posttraumatic stress disorder (PTSD) symptoms during the past month were assessed using the Primary Care PTSD Screen, a four-item self-report questionnaire with good reliability and sensitivity, specificity, and efficiency for identifying PTSD (Prins et al., 2004). Parents completed the Child Behavior Checklist (CBCL), a widely used measure of child psychopathology with documented reliability and validity and procedures for determining clinical significance of scores standardized to national norms (Achenbach, 1991).

BERK

AND

ASARNOW

Service Use. The Service Use and Adjustment Problem Screen (SUAPS; Glynn, Asarnow, & Asarnow, 2003) was used to assess service use and problem behaviors in the past 6 months. Service use items were prior ED visits, inpatient/residential and outpatient treatment for mental health/substance use problems, and medication treatment for mental health/substance use problems. Problem behavior items included substance abuse, homelessness, being expelled from school, incarceration, and being out of work. SUAPS variables have shown adequate reliability and predictive validity (Asarnow, Baraff, et al., 2011; Asarnow, Porta, et al., 2011; Glynn et al., 2003). Family Functioning. Family conflict in the past 2 weeks was assessed by youth report on the 20-item Conflict Behavior Questionnaire (CBQ), a psychometrically sound measure (Robin & Foster, 1989). Life Stressors. The YPIC Life Events Scale (Asarnow et al., 2008; Fordwood, Asarnow, Huizar, & Reise, 2007), modified to include items associated with suicide, assessed stressful events the youth may have experienced in the past 6 months. Items included the following: exposure to suicide/attempted suicide; romantic breakups; fights with romantic partners; deaths; injuries; illness; car accidents; assaults; arguments with friends; parent divorce/separation; parent remarriage; arguments with parents; parent criticism/ disapproval; financial problems; school suspensions/expulsions; physical fights; arrested/ legal problems; and pregnancy/got someone pregnant. We examined rates of specific events and total number of stresses. Best Estimate Ratings of Youth Suicidality at the Time of ED Visit Best estimate ratings were made by trained independent judges using all available sources of information obtained at the time of the ED visit, including youth and parent baseline questionnaires, youth and parent verbal reports, verbal reports of treating ED staff, and ED medical records.

349 Suicide ideation was rated on a dichotomous scale (0 = No, 1 = Yes), and suicide attempts were rated on a three-point scale (0 = No, 1 = Possible, and 2 = Yes). Possible and yes responses were later collapsed into a single “yes” category. Suicidal ideation and suicide attempts were considered to be mutually exclusive, and youth were rated as suicide ideators only if the reason for the ED visit was not a suicide attempt. Judges were instructed to prioritize youth and parent self-reports in making their best estimate ratings. That is, endorsement of suicidal ideation or a suicide attempt as the reason for the ED visit by either the youth or parent was considered to be a positive response, unless directly contradictory information was obtained from another source that the judge deemed to be more credible (e.g., the ED clinician reported that the youth or parent denied that youth had made a suicide attempt). Judges were provided with a definition of a suicide attempt that included the intent to die and reviewed youths’ self-reports about intent to die (for those who endorsed a suicide attempt as the reason for the ED visit) when making their ratings. However, it was not required that the youth had positively endorsed this item to be judged as having made a suicide attempt if information about intent was obtained or could have been inferred from other sources of information. Twenty-five percent of the best estimate ratings were also independently rated by a second trained judge (n = 45) to calculate reliability, which was measured using Cohen’s kappa coefficient (Cohen, 1960). Kappas for ratings of suicide attempts (k = .78) and suicidal ideation (j = .73) were substantial (Landis & Koch, 1977). Analysis Plan To examine the degree of overlap in judgments of the reason for the ED visit (suicidal ideation or a suicide attempt) by different informants, we compared youth, parent, and best estimate ratings made at

350

ASSESSMENT

OF

SUICIDAL YOUTH

IN THE

ED

for both suicide attempts (j = .53, p < .001) and for suicidal ideation (j = .52. p < .001). Finally, as shown in Tables 6 and 7, youth and parent reports showed fair agreement for suicide attempts (j = .38, p < .001) and suicidal ideation (j = .37, p < .001). Seventy-seven percent of adolescents who were judged by best estimate raters as coming to the ED visit for a suicide attempt also reported some intent to die either “ambiguous” (n = 29; 42%) or “definite” (n = 24; 35%) associated with their suicide attempt, v2 (3) = 29.38, p < .001. These findings suggest that youth selfreports of suicide attempts are most often consistent with the definition of suicide attempts as including some “nonzero” intent to die (Crosby et al., 2011; O’Carroll et al., 1996; Posner et al., 2007; Silverman et al., 2007) and also highlight that intent is frequently ambiguous.

the time of the ED visit using Cohen’s kappa coefficient (Cohen, 1960). Second, we examined whether youths presenting to the ED due to a SA differed from those presenting with SI on demographic and clinical characteristics, as well as recent stressful life events. Subjects were divided into SA and SI groups based on best estimate ratings. These comparisons were conducted using chi-square analyses for categorical variables and independent-samples t tests for continuous variables. A summary of the criteria used to assign youth to SA and SI groups for each set of analyses is provided in Table 1.

RESULTS

Agreement Between Youth, Parent, and Best Estimate Ratings of the Reason for the ED Visit

Comparisons of Youths Presenting to the ED for Suicide Attempts Versus Ideation

As shown in Tables 2–7, all kappas were significant and ranged from “substantial” to “fair” in the level of agreement between raters (Landis & Koch, 1977). In particular, as shown in Table 2, best estimate ratings and youth self-reports showed substantial agreement on suicide attempts (j = .71 p < .001) and, as shown in Table 3, moderate agreement on suicidal ideation (j = .58, p < .001). As shown in Tables 4 and 5, best estimate ratings and parent reports showed moderate agreement

Demographics. Descriptive information on youths presenting to the ED for SAs versus SI, as determined by best estimate ratings, is presented in Table 8. No significant differences in gender, age, and ethnicity were observed between groups. Both groups were predominately female and Latina. The overall sample had a mean age of 14.71 (range: 10–18). In addition, no significant differences were found between

TABLE 1

Criteria Used to Assign Youth to SA and SI Groups Classification into grouping variables based on Analysis Agreement between youth, parent, and best estimate ratings of the reason for the ED visit Comparisons of youths presenting to the ED for suicide attempts versus ideation

• Youths’ self-reports of the reason for ED visit • Parents’ self-reports of the reason for ED visit • Best estimate ratings of the reason for ED visit • Best estimate ratings of the reason for ED visit

BERK

AND

ASARNOW

351

TABLE 2

Agreement Matrix for Best Estimate Ratings and Youth Self-Reports of Suicide Attempts as the Reason for the ED Visit Best estimate rating of suicide attempt

Youth report of suicide attempt

Yes No Total

Yes

No

Total

86 (90%)a 10 (10%) 96 (53%)

16 (19%) 69 (81%) 85 (47%)

102 (56%) 79 (44%) 181 (100%)

j = .71; p < .001. a Refers to column percent. TABLE 3

Agreement Matrix for Best Estimate Ratings and Youth Self-Reports of Suicidal Ideation as the Reason for the ED Visit Best estimate rating of suicidal ideation Yes Youth report of suicidal ideation

Yes No Total

a

54 (64%) 31 (36%) 85 (100%)

No

Total

6 (6%) 90 (94%) 96 (100%)

60 (33%) 121 (67%) 181 (100%)

j = .58, p < .001. a Refers to column percent. TABLE 4

Agreement Matrix for Best Estimate Ratings and Parent Self-Reports of Suicide Attempts as the Reason for the ED Visit Best estimate rating of suicide attempt

Parent report of suicide attempt

Yes No Total

Yes

No

Total

56 (61%)a 36 (39%) 92 (100%)

5 (6%) 73 (94%) 78 (100%)

61 (36%) 109 (64%) 170 (100%)

j = .53; p < .001. a Refers to column percent.

the two ED sites in suicide attempts versus ideation as the reason for the ED visit, with both sites having slightly more attempters than ideators. Between-Group Differences in Clinical Characteristics. As shown in Table 8, best estimate ratings of the reason for the ED visit showed that youth who were rated as coming to the ED for a suicide attempt

were significantly more likely to report a history of suicide attempts during the past year than those rated as suicide ideators, v2 (2) = 35.19, p < .001. Of the suicide attempters, 32% reported a history of multiple suicide attempts in the past year, 53% reported a single suicide attempt, and 15% reported a history of suicidal ideation. Of the suicide ideators, 21% reported a history

352

ASSESSMENT

OF

SUICIDAL YOUTH

IN THE

ED

TABLE 5

Agreement Matrix for Best Estimate Ratings and Parent Self-Reports of Suicidal Ideation as the Reason for the ED Visit Best estimate rating of suicidal ideation

Parent report of suicidal ideation

Yes No Total

Yes

No

Total

61 (79%)a 16 (21%) 77 (100%)

25 (27%) 67 (73%) 92 (100%)

86 (51%) 83 (49%) 169 (100%)

j = .52, p < .001. a Refers to column percent.

TABLE 6

Agreement Matrix for Youth and Parent Reports of Suicide Attempts as the Reason for the ED Visit Youth self-report of suicide attempt

Parent report of suicide attempt

Yes No Total

Yes

No

Total

52 (53%)a 46 (47%) 98 (100%)

9 (12.5%) 63 (87.5%) 72 (100%)

61 (36%) 109 (64%) 170 (100%)

j = .38; p < .001. a Refers to column percent.

TABLE 7

Agreement Matrix for Youth and Parent Reports of Suicidal Ideation as the Reason for the ED Visit Youth self-report of suicidal ideation

Parent report of suicidal ideation

Yes No Total

Yes

No

Total

43 (80%)a 11 (20%) 54 (100%)

43 (37%) 72 (63%) 115 (100%)

86 (51%) 83 (49%) 169 (100%)

j = .37, p < .001. a Refers to column percent.

of multiple attempts, 24% reported a history of a single attempt, and 55% reported no prior suicide attempts. Hence, the vast majority of youth seen in the ED for a suicide attempt (85%) reported a history of prior suicide attempts in the past year, whereas slightly less than half of the suicide ideators (45%) reported prior suicidal behavior.

As shown in Table 8, there was only one other significant difference between youths presenting to the ED due to SA versus SI. On the CBCL, parent-reported levels of delinquent behavior were significantly higher for the SA group than for the SI group (SA: M = 67.48, SD; SI: M = 63.29, SD; t(164) = 2.15, p < .033). There was a marginal trend toward higher depressive

BERK

AND

ASARNOW

353

TABLE 8

Comparison of Youths with a Best Estimate Rating of Suicide Attempt Versus Suicidal Ideation Suicide attempt N = 96 Demographics Female gender Ethnicity White Black Hispanic Other Age ED Site UCLA Harbor-UCLA History of Suicidal Behavior in the Past Year*** No suicide attempts One suicide attempt Two or more suicide attempts Psychopathology Externalizing behavior (CBCL) Depression (CESD) PTSD Substance use past 6 months Service Use (past 6 months) ED visits Inpatient treatment Mental health treatment Medication treatment

Suicidal ideation N = 85

65 (67.7%)

60 (70.6%)

27 (28.1%) 16 (16.7%) 44 (45.8%) 9 (9.4%) 14.65  1.85

33 (38.8%) 7 (8.2%) 38 (44.7%) 7 (8.2%) 14.78  2.07

43 (44.8%) 53 (55.2%)

37 (43.5%) 48 (56.5%)

14 (14.6%) 51 (53.1%) 31 (32.2%)

47 (55.3%) 20 (23.5%) 18 (21.2%)

32.18  11.68 1.77  1.57 16 (16.8%)

35.28  11.81* 1.90  1.53a 15 (17.9%)

26 21 49 35

(27.1%) (21.9%) (51%) (41.2%)

26 23 55 32

(30.6%) (27.1%) (64.7%)* (33.3%)

Note. Data are presented as mean  SD for continuous variables and n (%) for categorical variables. ***p < .001, ** p < .05, *p < .10. a Due to missing data, this analysis included N = 89 for the SA group and N = 80 for the SI group.

symptoms on the CES-D in the SI group (M = 35.28, SD = 11.81) than in the SA group (M = 32.18, SD = 11.68, t(179) = 1.77, p < .077) as well as a trend for youths coming the ED for SI to be more likely to be receiving mental health treatment in the prior 6 months (64.7% for SI group versus 51% for SA group), v2 (1) = 3.44, p < .06. There were no significant differences between groups in ED visits in other types of treatment received in the past 6 months, including medical health care, psychiatric medications, or psychiatric inpatient visits. Family functioning and life stressors also did not significantly differ by condition.

DISCUSSION

In the present study we examined factors impacting the evaluation of suicidal youth in the ED. Accurate assessment of adolescents presenting to the ED with suicidal thoughts and behaviors is critical in ensuring the safety of these youth and in making appropriate treatment decisions. First, we looked at rates of agreement between ratings made by adolescents, parents, and trained judges of the reason for the ED visit (e.g., suicidal ideation or a suicide attempt). Consistent with prior work, parent/child agreement on the youth’s degree

354 of suicidality was fair to moderate (Cloutier et al., 2010; Klaus et al., 2009). These findings illustrate the usefulness of obtaining information from both the adolescent and the parent when assessing the level of risk in the ED setting, as is consistent with the recommendations of current practice parameters for assessing adolescent suicidality in the ED (American Academy of Child & Adolescent Psychiatry, 2001). Ratings made by trained judges regarding the reason for the ED visit showed greater consistency with youth ratings than with parent ratings, particularly regarding suicide attempts, for which agreement was substantial. These results suggest that independent judges viewed youth reports as generally reliable and perhaps more accurate than reports of parents who could not directly observe intent to die and may not have known about suicidal behaviors of their children. Hence, obtaining information from the youth seen in the ED is critical in accurately assessing risk and determining disposition. Consistent with the surveillance definition proposed by the Centers for Disease Control (CDC; Crosby et al., 2011), and the general approach in the United States of defining suicide attempts as nonfatal selfinjurious behaviors with some (nonzero) intent to die as a result of the behavior (Crosby et al., 2011; O’Carroll et al., 1996; Posner et al., 2007; Silverman et al., 2007), most youths (77%) who were judged to have a suicide attempt as the reason for the ED visit also reported some intent to die associated with their attempts. However, the relatively low number of youths reporting “definite” suicide intent associated with their self-injurious behavior underscores the fact that youths are often uncertain regarding their intent when engaging in self-injurious behavior. Given literature indicating that intent to die during a suicide attempt predicts later suicide death in adults (Brown et al., 2004) and is associated with increased risk factors for suicide deaths (Nock & Kessler, 2006), suicidal “intent” should be weighted heavily in clinical decision mak-

ASSESSMENT

OF

SUICIDAL YOUTH

IN THE

ED

ing. The current data also underscore the importance of treating youth reports of suicide attempts as serious rather than regarding some suicidal behaviors as “gestures” or means of getting attention or interpersonal goals met. Given that adolescents were not provided with a definition of a suicide attempt to guide their ratings, our findings indicate that most teens instinctively defined suicide attempts similarly to clinicians and drew distinctions between suicide attempts and nonsuicidal self-harm behaviors (e.g., those that were not performed with the intent to die). However, given recent research indicating that nonsuicidal self-injurious behavior is also a strong predictor of future suicide attempts, indeed a stronger predictor than prior suicide attempts among depressed adolescents (Asarnow, Baraff, et al., 2011; Asarnow, Porta, et al., 2011; Wilkinson, Kelvin, Roberts, Dubicka, & Goodyer, 2011), careful evaluation of youths presenting with any deliberate selfharm behaviors is also needed. Taken together, these results underscore the importance of youth self-report in assessing suicidality in the ED. This finding corresponds with other recent studies showing that youth were more likely to endorse self-harm on a questionnaire than during a clinical interview and is consistent with other data indicating greater sensitivity of self-report versus clinician-administered measures when assessing sensitive behaviors (Asarnow, McArthur, Hughes, Barbery, & Berk, 2012; Connor & Rueter, 2009; Ougrin & Boege, 2013; Prinstein, Nock, Spirito, & Grapentine, 2001). Given the potentially fatal consequences of failing to detect suicidal behavior, these data underscore the value of using self-report measures in ED screening. Although gathering data from multiple informants is always the preferred strategy, given the challenges of the ED setting, it is not always possible to employ an optimal assessment strategy and parents are not always present in the ED, particularly for youths who are brought to the ED by ambulance or

BERK

AND

ASARNOW

police. Thus, it is important to recognize the limitations and contributions of different assessment data. Our finding of few clinical differences in the characteristics of youths presenting to the ED with suicide attempts and those presenting with suicidal ideation underscores the fact that these are overlapping populations. Although suicide attempters were more likely to report having prior suicide attempts, approximately half of the youths presenting to the ED with current suicidal ideation reported a history of suicide attempts within the past year, putting them at high risk of future suicide attempts (Lewinsohn, Rohde, & Seely, 1994; Shaffer et al., 1996). Hence, these data suggest the need for careful evaluation and management of both suicide ideators and attempters seen in the ED and the particular importance of assessing past suicidal behavior when making treatment decisions. The level of risk among youth ED patients presenting with current suicidal ideation in the absence of current suicidal behavior should not be underestimated. Even if youth with suicidal ideation do not meet criteria for inpatient hospitalization at the time of the ED visit, plans for comprehensive outpatient followup are needed. Consistent with literature documenting a link between suicidal behavior and delinquency (see Thompson, Ho, & Kingree, 2007), parents reported significantly higher levels of delinquent behaviors in the SA group than in the SI group, underscoring that suicide attempts are associated with a pattern of severe behavioral problems (e.g., Asarnow et al., 2008; Shaffer et al., 1996). These data are also consistent with the results suggesting that aggression and impulsive traits are risk factors for suicide and suicide attempts and associated with increased likelihood that suicidal ideation will progress to suicide attempts (Mann et al., 2009). Interestingly, youths presenting to the ED with suicidal ideation versus attempts were somewhat more likely to report receiving mental health treatment in

355 the past 6 months. This may represent a positive benefit of treatment, in that youth with suicidal ideation are following safety plans made with their mental health providers to seek help prior to making a suicide attempt. However, ED visits for suicidal ideation may suggest that treatment in the community is not effective in reducing suicidality, consistent with the lack of empirically supported treatments for adolescent suicide attempters (for reviews, see Gould, Greenberg, Velting, & Shaffer, 2003; Ougrin et al., 2012). Although there was only a nonsignificant trend for youth with suicidal ideation to report greater depressive symptoms than those seen in the ED following a suicide attempt, these findings are consistent with the frequent finding of strong associations between suicidal ideation and self-reported depressive symptoms (Asarnow, 1992; Asarnow, Berk, et al., 2009; Asarnow, Emslie, et al., 2009). Although this study included one of the largest available samples of suicidal youth ED patients, study limitations include the limited number of ED sites and that sites were not selected at random. Our observations were cross sectional; longitudinal research is needed to determine prospective predictors of suicide attempt risk. Because our overall goal was to inform ED practice, we adopted an “effectiveness” perspective and used brief questionnaires that could be incorporated into fast-paced ED assessments. More detailed assessments of suicidal intent, ideation, attempts, and NSSI, such as structured clinical interviews like the Columbia Suicide Severity Rating Scale (Posner et al., 2011) or the Suicide Attempt and Self-Injury Interview (Linehan, Comtois, Brown, Heard, & Wagner, 2006), might yield different results. In particular, the use of structured clinical interviews that thoroughly assess current and past suicidal thoughts and behaviors is recommended as part of follow-up evaluation and treatment of suicidal youth identified in the ED (for a detailed review of measures, see Goldston, 2000).

356 In conclusion, both the National Prevention Plan (National Prevention Council, 2011) and the National Strategy for Suicide Prevention (U.S. Department of Health and Human Services, 2001) emphasize the potential preventive value of screening youths for suicide and suicide attempt risk in EDs. The ED is a unique service setting where youths with the most severe suicidal thoughts and behaviors are likely to be evaluated. ED clinicians need to act quickly and accurately to make decisions affecting youth

ASSESSMENT

OF

SUICIDAL YOUTH

IN THE

ED

safety. The present data can inform efforts to screen, evaluate, and treat suicidal youth ED patients. Our findings highlight the importance of emphasizing the youth’s report of his or her suicidality in clinical decision making; suggest that youths’ conceptualizations of suicide attempts are likely to be consistent with the field’s definitions; and suggest that assessment in the ED of past suicide attempts, as well as present suicidal thoughts and behaviors, is critical in determining future risk.

REFERENCES ACHENBACH, T. M. (1991). Integrative guide for the 1991 CBCL/4-18, YSR, and TRF profiles. Burlington, VT: Department of Psychiatry, University of Vermont. American Academy of Child and Adolescent Psychiatry. (2001). Practice parameters for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 40 (7 Supplement), 24S–51S. ASARNOW, J. R. (1992). Suicidal ideation and attempts during middle childhood: Associations with perceived family stress and depression among child psychiatric inpatients. Journal of Clinical Child Psychology, 21, 33–40. ASARNOW, J. R., BARAFF, L. J., BERK, M. S., GROB, C. S., DEVICH-NAVARRO, M., SUDDATH, R., ET AL. (2008). Suicidal pediatric emergency department patients: A 2-site evaluation of suicide ideators, single attempters, and repeat attempters. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 958–966. ASARNOW, J. R., BARAFF, L. J., BERK, M. S., GROB, C. G., NAVARRO, M. D., & TANG, L. (2011). An emergency department intervention for linking pediatric suicidal patients to followup mental health treatment. Psychiatric Services, 62, 1303–1309. ASARNOW, J. R., BERK, M. S., & BARAFF, L. J. (2009). Family intervention for suicide prevention: A specialized emergency department intervention for suicidal youth. Professional Psychology, 40, 118–125. ASARNOW, J. R., EMSLIE, G., CLARKE, G., WAGNER, K., SPIRITO, A., VITIELLO, B., ET AL. (2009). Treatment of SSRI-resistant depression in adolescents: Predictors and moderators of treatment response. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 331– 340.

ASARNOW, J. R., MCARTHUR, D., HUGHES, J., BARBERY, V., & BERK, M. S. (2012). Suicide attempt risk in youths: Utility of the HarkavyAsnis suicide scale for monitoring risk levels. Suicide and Life-Threatening Behavior, 42, 694–698. ASARNOW, J., PORTA, G., SPIRITO, A., EMSLIE, G., CLARKE, G., WAGNER, K., ET AL. (2011). Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: Findings from the TORDIA study. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 772–781. BECK, A. T., SCHUYLER, D., & HERMAN, I. (1974). Development of suicidal intent scales. In A. T. Beck, H. L. Resnik, & D. J. Lettieri (Eds.), The prediction of suicide (pp. 45–56). Bowie, MD: Charles Press. BECK, A. T., & STEER, R. A. (1989). Clinical predictors of eventual suicide: A 5- to 10-year prospective study of suicide attempters. Journal of Affective Disorders, 17, 203–209. BRENER, N. D., KANN, L., KINCHEN, S. A., GRUNBAUM, J. A., WHALEN, L., EATON, D., ET AL. (2004). Methodology of the youth risk behavior surveillance system. MMWR Recommendations and Reports, 53, 1–13. BRETON, J., TOUSIGNANT, M., BERGERON, L., & BERTHIAUME, C. (2002). Informant-specific correlates of suicidal behavior in a community survey of 12- to 14-year-olds. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 723–730. BROWN, G. K., HENRIQUES, G. R., SOSDJAN, D., & BECK, A. T. (2004). Suicide intent and accurate expectations of lethality: Predictors of medical lethality and suicide attempts. Journal of Consulting and Clinical Psychology, 72, 1170–1174. Centers for Disease Control and Prevention. (2011). 10 leading causes of death by age group.

BERK

AND

ASARNOW

Retrieved September 9, 2014, from http:// www.cdc.gov/injury/wisqars/pdf/leading_causes_ of_death_by_age_group_2011-a.pdf CLARKE, G. N., HAWKINS, W., MURPHY, M., SHEEBER, L. B., LEWINSOHN, P. M., & SEELEY, J. R. (1995). Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: A randomized trial of group cognitive intervention. Journal of the Academy of Child and Adolescent Psychiatry, 34, 312– 321. CLOUTIER, P., KENNEDY, A., MAYSENHOELDER, H., GLENNIE, E. J., CAPPELLI, M., & GRAY, C. (2010). Pediatric mental health concerns in the emergency department: Caregiver and youth perceptions and expectations. Pediatric Emergency Care, 26, 99–106. COHEN, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20, 37–46. CONNOR, J., & RUETER, M. (2009). Predicting adolescent suicidality: Comparing multiple informants and assessment techniques. Journal of Adolescence, 32, 619–631. CROSBY, A. E., ORTEGA, L., & MELANSON, C. (2011). Self-directed violence surveillance: Uniform definitions and recommended data elements, Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. ESPOSITO, C., SPIRITO, A., BOERGERS, J., & DONALDSON, D. (2003). Affective, behavioral, and cognitive functioning in adolescents with multiple suicide attempts. Suicide and LifeThreatening Behavior, 33, 389–399. FORDWOOD, S. R., ASARNOW, J. R., HUIZAR, D. P., & REISE, S. P. (2007). Suicide attempts among depressed adolescents in primary care. Journal of Clinical Child and Adolescent Psychology, 36, 392–404. FORMAN, E. M., BERK, M. S., HENRIQUES, G. R., BROWN, G. K., & BECK, A. T. (2004). History of multiple suicide attempts as a behavioral marker of severe psychopathology. The American Journal of Psychiatry, 161, 437–443. GLYNN, S. M., ASARNOW, J. R., & ASARNOW, R. (2003). The development of acute post-traumatic stress disorder after orofacial injury: A prospective study in a large urban hospital. Journal Oral and Maxillofacial Surgery, 61, 785–792. GOLDSTON, D. (2000). Assessment of suicidal behaviors and risk among children and adolescents. Technical report submitted to NIMH under Contract No. 263-MD-909995. GOLDSTON, D. B., DANIEL, S., REBOUSSIN, D. M., & KELLEY, A. (1996). First-time suicide attempters, repeat attempters and previous attempters on an adolescent inpatient psychiatry

357 unit. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 631–639. GOULD, M. S., GREENBERG, T., VELTING, D. M., & SHAFFER, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 386–405. HARRIS, H., & MYERS, W. C. (1997). Adolescents’ misperceptions of the dangerousness of acetaminophen in overdose. Suicide and LifeThreatening Behavior, 27, 274–277. KAHN, L., KINCHEN, S., SHANKLIN, S. L., FLINT, K. H., & HAWKINS, J., ET AL. (2013). Youth Risk Behavior Surveillance — United States, 2013. Morbidity and Mortality Weekly Report. Retrieved from http://www.cdc.gov/ HealthyYouth/yrbs/index.htm KASHANI, J. H., GODDARD, P., & REID, J. C. (1989). Correlates of suicidal ideation in a community sample of children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 912–917. KENNEDY, S. P., BARAFF, L. J., SUDDATH, R. L., & ASARNOW, J. R. (2004). Emergency department management of suicidal adolescents. Annals of Emergency Medicine, 43, 452–460. KLAUS, N. M., MOBILIO, A., & KING, C. A. (2009). Parent–adolescent agreement concerning adolescents’ suicidal thoughts and behaviors. Journal of Clinical Child and Adolescent Psychology, 38, 245–255. LANDIS, J. R., & KOCH, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159–174. LEWINSOHN, P. M., ROHDE, P., & SEELY, J. R. (1994). Psychosocial risk factors for future adolescent suicide attempts. Journal of Consulting and Clinical Psychology, 62, 297–305. LINEHAN, M. M., COMTOIS, K., BROWN, M. Z., HEARD, H. L., & WAGNER, A. (2006). Suicide attempt self-injury interview (SASII): Development, reliability, and validity of a scale to assess suicide attempts and intentional selfinjury. Psychological Assessment, 18, 303–312. MANN, J., ARANGO, V. A., AVENEVOLI, S., BRENT, D. A., CHAMPAGNE, F. A., CLAYTON, P., ET AL. (2009). Candidate endophenotypes for genetic studies of suicidal behavior. Biological Psychiatry, 65, 556–563. National Prevention Council. (2011). National prevention strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, . NICE. (2004). Self-harm: The short term physical and psychological management and secondary prevention of self-harm in primary and secondary care [NICE Clinical Guideline, no. 16]. London: Gaskell & British Psychological Society.

358 NOCK, M. K., & KESSLER, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the national comorbidity survey. Journal of Abnormal Psychology, 115, 616–623. O’CARROLL, P. W., BERMAN, A., MARIS, R. W., MOSCICKI, E. K., TANNEY, B. L., & SILVERMAN, M. M. (1996). Beyond the tower of Babel: A nomenclature for suicidology. Suicide and LifeThreatening Behavior, 26, 237–252. OUGRIN, D., & BOEGE, I. (2013). The self harm questionnaire: A new tool designed to improve identification of self harm in adolescents. Journal of Adolescence, 36, 221–225. OUGRIN, D., TRANAH, T., LEIGH, E., TAYLOR, L., & ASARNOW, J. R. (2012). Practitioner review: Self-harm in adolescents. Journal of Child Psychology and Psychiatry, 53, 337–350. POSNER, K., BROWN, G. K., STANLEY, B., BRENT, D. A., YERSHOVA, K. V., OQUENDO, M. A., ET AL. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266–1277. POSNER, K., OQUENDO, M. A., GOULD, M., STANLEY, B., & DAVIES, M. (2007). Columbia classification algorithm of suicide assessment (CCASA): Classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. American Journal of Psychiatry, 164, 1035–1043. PRINS, A., OUIMETTE, P., KIMERLING, R., CAMERON, R. P., HUGELSHOFER, D. S., SHAW HEGWER, J., ET AL. (2004). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9–14. PRINSTEIN, M. J., NOCK, M. J., SPIRITO, A., & GRAPENTINE, W. L. (2001). Multimethod assessment of suicidality in adolescent psychiatric inpatients: Preliminary results. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1053–1061. RADLOFF, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. ROBIN, A. L., & FOSTER, S. L. (1989). Negotiating parent–adolescent conflict: A behavioral family systems approach. New York: Guilford. ROSENBERG, H. J., JANKOWSKI, M. K., SENGUPTA, A., WOLFE, R. S., WOLFORD, G., & ROSENBERG, S. D. (2005). Single and multiple suicide attempts and associated health risk factors in New Hampshire adolescents. Suicide and Life-Threatening Behavior, 35, 547–557. SHAFFER, D., GOULD, M. S., FISHER, P., TRAUTMAN, P., MOREAU, D., KLEINMAN, M.,

ASSESSMENT

OF

SUICIDAL YOUTH

IN THE

ED

ET AL. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339–348. SILVERMAN, M. M., BERMAN, A. L., SANDDAL, N. D., O’CARROLL, P. W., & JOINER, T. E. (2007). Rebuilding the tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Background, rationale, and methodology. Suicide and Life-Threatening Behavior, 37, 248–263. SOURANDER, A. A., HELSTELA€ , L. L., & HELENIUS, H. H. (1999). Parent-adolescent agreement on emotional and behavioral problems. Social Psychiatry and Psychiatric Epidemiology, 34, 657–663. STEIN, D., APTER, A., RATZONI, G., HAREVEN, D., & AVIDAN, G. (1998). Association between multiple suicide attempts and negative affects in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 488–494. THOMPSON, M. P., HO, C., & KINGREE, J. B. (2007). Prospective associations between delinquency and suicidal behaviors in a nationally representative sample. Journal of Adolescent Health, 40, 232–237. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General and National Action Alliance for Suicide Prevention. (2012). 2012 National strategy for suicide prevention: Goals and objectives for action. Washington, DC: Author. VELEZ, C. N., & COHEN, P. (1988). Suicidal behavior and ideation in a community sample of children: Maternal and youth reports. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 349–356. WAGNER, B. M., WONG, S. A., & JOBES, D. A. (2002). Mental health professionals’ determinations of adolescent suicide attempts. Suicide and Life-Threatening Behavior, 32, 284–300. WALKER, M., MOREAU, D., & WEISSMAN, M. M. (1990). Parents’ awareness of children’s suicide attempts. The American Journal of Psychiatry, 147, 1364–1366. WALRATH, C. M., MANDELL, D. S., LIAO, Q., HOLDEN, E., DE CAROLIS, G., SANTIAGO, R. L., ET AL. (2001). Suicide attempts in the comprehensive community mental health services for children and their families’ program. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1197–1205. WILKINSON, P., KELVIN, R., ROBERTS, C., DUBICKA, B., & GOODYER, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the adolescent depression antidepressants and psychotherapy trial (ADAPT). The American Journal of Psychiatry, 168, 495–501.

BERK

AND

ASARNOW

WINTERSTEEN, M. B., DIAMOND, G. S., & FEIN, J. A. (2007). Screening for suicide risk in the pediatric emergency and acute care setting. Current Opinion in Pediatrics, 19, 398–404. ZIMMERMAN, J. K., & ASNIS, G. M. (1991). Parents’ knowledge of children’s suicide attempts.

359 The American Journal of Psychiatry, 148, 1091– 1092. Manuscript Received: July 11, 2013 Revision Accepted: August 8, 2014