AFSP Issues Statement Urging Screening for Youth Suicide Risk

The U.S. Preventive Services Task Force (USPSTF) recently issued draft recommendations on screening for anxiety in children and adolescents. Given the increasing rates of suicide and mental health issues among U.S. youth, we at the American Foundation for Suicide Prevention are concerned with the USPSTF’s finding of insufficient evidence for implementing screening for suicide risk among youth, which is misaligned with recent expert recommendations. The USPSTF findings may cast doubt among healthcare providers on the importance of suicide screening and preventive care.

For this reason, our partner organization on the Blueprint for Youth Suicide Prevention, the American Academy of Pediatrics (AAP), collaborated with us to identify key weaknesses of the USPSTF draft report. Our goal is to urge the Task Force to review the evidence further and consider aligning with Bright Futures and the AAP Blueprint for Youth Suicide Prevention in recommending routine suicide screening starting at age 12.

Read the full statement below.

**

May 9, 2022

Carol M. Mangione, M.D., M.S.P.H., Chair
U.S. Preventive Services Task Force
5600 Fishers Lane
Mail Stop 06E53A
Rockville, MD 20857

Dear Chair Dr. Mangione:

The American Foundation for Suicide Prevention is grateful for the opportunity to share comments on the draft Recommendations Statement released by the U.S. Preventive Services Task Force (USPSTF) on screening for depression and suicide risk in children and adolescents. We support the recommendation to screen for major depressive disorder (MDD) in asymptomatic adolescents, but we have concerns about the decision related to suicide screening and encourage the USPSTF to revisit existing research on this topic with attention to peer-reviewed literature highlighted in this response. Specifically, we request that the task force consider adding a recommendation for suicide screening for youth ages 12 and older.

The US Surgeon General and other groups recently declared a state of emergency related to youth mental health. Suicide is the second leading cause of death among youth 10-17 years of age in the United States, with significant disparities by race, ethnicity, gender, and sexual identity. Suicide and suicidal behavior among youth are major public health crises. While the overall U.S. suicide rate decreased in 2020 for the second consecutive year, the decline was not universal. Notably, youth, young adults, Black and Hispanic males and multi-racial females all showed concerning increases in suicide rates during the early phase of the pandemic. Our children should grow, thrive, and live long, healthy lives. Yet over a quarter of youth deaths in the U.S. are from suicide, which could potentially be prevented. Preventing youth suicide depends on several strategies from the public health model, but chief among them is identifying those at risk so that supportive strategies can be employed.

Between April and October 2020, the proportion of children between the ages of 5 and 11 and adolescents ages 12 to 17 visiting an emergency room due to a mental health crisis increased by 24% and 31%, respectively.[1] In recent months, children’s hospitals have reported their highest number of children “boarding” in hospital emergency departments awaiting treatment.[2] During the first three quarters of 2021, children’s hospitals reported a 14% increase in mental health-related emergencies and a 42% increase in cases of self-injury and suicide, compared to the same time period in 2019.[3]

Faced with such data, in December 2021, the U.S. Surgeon General issued an advisory calling for a unified national response to the mental health challenges young people are facing.[4] Considering the rarity of such advisories, this further underscores the need for action to help stem the long-term impacts of the pandemic on the mental health and well-being of children and adolescents.

Our organization supports universal screening for suicide risk in youth ages 12 and older. This screening recommendation is included in the AAP/AFSP Blueprint for Youth Suicide Prevention which was developed using a rigorous process of literature review, four days of expert convenings with 90 stakeholder organizations, pediatricians, suicide and mental health experts, young adults with lived experience and parents who have lost children to suicide, and with a lens on equity. In addition, the 2022 update to the AAP/Bright Futures Recommendations for Preventive Pediatric Health Care (Periodicity Schedule) recommends screening for suicide risk for all youth ages 12 and older. The Task Force determined there was insufficient research that met inclusion or quality criteria to be able to make a recommendation statement, however our organization is aware of the substantial and growing body of evidence that support the implementation of such screenings. Moreover, many suicidal youth presenting to primary care do not have overt signs of distress or mental illness. When universal suicide screening is employed, it presents critical opportunities to employ feasible care steps that can be carried out in primary care settings, as outlined in the ASQ pathway and the Blueprint for Youth Suicide Prevention.

We respectfully encourage the USPSTF to review the following research and to consider changing the “I” recommendation for screening for suicide risk in asymptomatic children and adolescents.

• Validated approaches to assessing suicide risk in pediatric patients, including in primary care outpatient settings
  
  
  • Horowitz, M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., Wharff, E. A., Ginnis, K., Cannon, E., Joshi, P., & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of pediatrics & adolescent medicine, 166(12), 1170–1176. https://doi.org/10.1001/archpediatrics.2012.1276
    
  • Horowitz, M., Wharff, E. A., Mournet, A. M., Ross, A. M., McBee-Strayer, S., He, J. P., Lanzillo, E. C., White, E., Bergdoll, E., Powell, D. S., Solages, M., Merikangas, K. R., Pao, M., & Bridge, J. A. (2020). Validation and Feasibility of the ASQ Among Pediatric Medical and Surgical Inpatients. Hospital pediatrics, 10(9), 750–757. https://doi.org/10.1542/hpeds.2020-0087
  • Aguinaldo, L. D., Sullivant, S., Lanzillo, E. C., Ross, A., He, J. P., Bradley-Ewing, A., Bridge, J. A., Horowitz, M., & Wharff, E. A. (2021). Validation of the ask suicide-screening questions (ASQ) with youth in outpatient specialty and primary care clinics. General hospital psychiatry, 68, 52–58. https://doi.org/10.1016/j.genhosppsych.2020.11.006
  • King, C. A., Brent, D., Grupp-Phelan, J., Casper, T. C., Dean, J. M., Chernick, L. S., Fein, J. A., Mahabee-Gittens, M., Patel, S. J., Mistry, R. D., Duffy, S., Melzer-Lange, M., Rogers, A., Cohen, D. M., Keller, A., Shenoi, R., Hickey, R. W., Rea, M., Cwik, M., Page, K., … Pediatric Emergency Care Applied Research Network (2021). Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth. JAMA psychiatry, 78(5), 540–549. https://doi.org/10.1001/jamapsychiatry.2020.4576
  • Osman, , Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation with clinical and nonclinical samples. Assessment, 8(4), 443–454. https://doi.org/10.1177/107319110100800409
  • Horowitz, M., Wang, P. S., Koocher, G. P., Burr, B. H., Smith, M. F., Klavon, S., & Cleary, P. D. (2001). Detecting suicide risk in a pediatric emergency department: development of a brief screening tool. Pediatrics, 107(5), 1133–1137. https://doi.org/10.1542/peds.107.5.1133

• It is feasible to implement suicide risk screenings for pediatric patients
  • Horowitz, L. M., Bridge, J. A., Tipton, M. V., Abernathy, T., Mournet, A. M., Snyder, D. J., Lanzillo, , Powell, D., Schoenbaum, M., Brahmbhatt, K., Pao, M. (2022). Implementing suicide risk screening in a pediatric primary care setting: From research to practice. Academic Pediatrics, 22(2), 217-226. https://doi.org/10.1016/j.acap.2021.10.012
  • Roaten, , Horowitz, L. M., Bridge, J. A., Goans, C., McKintosh, C., Genzel, R., Johnson, C., & North, C. S. (2021). Universal Pediatric Suicide Risk Screening in a Health Care System: 90,000 Patient Encounters. Journal of the Academy of Consultation-Liaison Psychiatry, 62(4), 421–429. https://doi.org/10.1016/j.jaclp.2020.12.002
    
  • Rybczynski, S., Ryan, T. C., Wilcox, H. C., Van Eck, K., Cwik, M., Vasa, R. A., Findling, R. L., Slifer, , Kleiner, D., & Lipkin, P. H. (2021). Suicide Risk Screening in Pediatric Outpatient Neurodevelopmental Disabilities Clinics. Journal of developmental and behavioral pediatrics, 10.1097/DBP.0000000000001026. Advance online publication. https://doi.org/10.1097/DBP.0000000000001026
    
  • Sullivant, A., Brookstein, D., Camerer, M., Benson, J., Connelly, M., Lantos, J., Cox, K., & Goggin, K. (2021). Implementing Universal Suicide Risk Screening in a Pediatric Hospital. Joint Commission journal on quality and patient safety, 47(8), 496–502. https://doi.org/10.1016/j.jcjq.2021.05.001
    
  • Lois, B. H., Urban, T. H., Wong, C., Collins, E., Brodzinsky, L., Harris, M. A., Adkisson, H., Armstrong, , Pontieri, J., Delgado, D., Levine, J., & Liaw, K. R. (2020). Integrating Suicide Risk Screening into Pediatric Ambulatory Subspecialty Care. Pediatric quality & safety, 5(3), e310. https://doi.org/10.1097/pq9.0000000000000310
    
  • Vaughn, M., Sunny, C. E., Lindquist-Grantz, R., King, C., Brent, D., Boyd, S., & Grupp-Phelan, J. (2020). Successful Suicide Screening in the Pediatric Emergency Department: Youth, Parent, Researcher, and Clinician Perspectives. Archives of suicide research, 24(sup1), 124–141. https://doi.org/10.1080/13811118.2018.1541034
    
  • Inman, D., Matthews, J., Butcher, L., Swartz, C., & Meadows, A. L. (2019). Identifying the risk of suicide among adolescents admitted to a children's hospital using the Ask Suicide-Screening Questions. Journal of child and adolescent psychiatric nursing, 32(2), 68–72. https://doi.org/10.1111/jcap.12235
    
  • Patel, , Watts, C., Shiddell, S., Couch, K., Smith, A. M., Moran, M. J., & Conners, G. P. (2018). Universal Adolescent Suicide Screening in a Pediatric Urgent Care Center. Archives of suicide research : official journal of the International Academy for Suicide Research, 22(1), 118–127. https://doi.org/10.1080/13811118.2017.1304303

• Pediatric suicide risk screening is widely supported by patients and parents
  
  • Ross, A. M., White, E., Powell, D., Nelson, S., Horowitz, L., & Wharff, E. (2016). To Ask or Not to Ask? Opinions of Pediatric Medical Inpatients about Suicide Risk Screening in the The Journal of pediatrics, 170, 295–300. https://doi.org/10.1016/j.jpeds.2015.11.052
    
  • Ballard, D., Bosk, A., Snyder, D., Pao, M., Bridge, J. A., Wharff, E. A., Teach, S. J., & Horowitz, L. (2012). Patients' opinions about suicide screening in a pediatric emergency department. Pediatric emergency care, 28(1), 34–38. https://doi.org/10.1097/PEC.0b013e31823f2315
    
  • Ballard, E. D., Stanley, I. H., Horowitz, L. M., Pao, M., Cannon, E. A., & Bridge, J. A. (2013). Asking Youth Questions About Suicide Risk in the Pediatric Emergency Department: Results From a Qualitative Analysis of Patient Clinical pediatric emergency medicine, 14(1), 20–27. https://doi.org/10.1016/j.cpem.2013.01.001
    
  • O'Mara, R. , Hill, R. M., Cunningham, R. M., & King, C. A. (2012). Adolescent and parent attitudes toward screening for suicide risk and mental health problems in the pediatric emergency department. Pediatric emergency care, 28(7), 626–632. https://doi.org/10.1097/PEC.0b013e31825cfb10
    
  • Mournet, A. M., Greenbaum, R., Thurm, A., Weinheimer, L., Lowry, N. J., Bridge, J.A., Pao, M., & Horowitz, L.M. (2021). Opinions on youth suicide risk screening from individuals with neurodevelopmental disorders and their therapists: A pilot study. Adolescents, 1(4), 473-480. https://doi.org/10.3390/adolescents1040036
    
  • Tipton, V., Arruda-Colli, M., Bedoya, S. Z., Pao, M., & Wiener, L. (2021). The acceptability of screening for suicide risk among youth in outpatient medical settings: Child and parent perspectives. Journal of psychosocial oncology, 39(6), 789–795. https://doi.org/10.1080/07347332.2020.1856997
    
  • Williams, R., Ho, M. L., & Grupp-Phelan, J. (2011). The acceptability of mental health screening in a pediatric emergency department. Pediatric emergency care, 27(7), 611–615. https://doi.org/10.1097/PEC.0b013e318222554e
• Suicide risk screening identifies at-risk youth not identified by depression screening
  • Kemper AR, Hostutler CA, Beck K, Fontanella CA, Bridge JA. Depression and Suicide-Risk Screening Results in Pediatric Primary Care. Pediatrics. 2021 Jul;148(1):e2021049999. doi: 10.1542/peds.2021-049999. Epub 2021 Jun 7. PMID: 34099503.
  • Horowitz LM, Mournet AM, Lanzillo E, He JP, Powell DS, Ross AM, Wharff EA, Bridge JA, Pao M. Screening Pediatric Medical Patients for Suicide Risk: Is Depression Screening Enough? J Adolesc Health. 2021 Jun;68(6):1183-1188. doi: 10.1016/j.jadohealth.2021.01.028. Epub 2021 Mar 9. PMID: 33712380; PMCID: PMC8154669.
• There are evidence-based suicide prevention treatments for pediatric patients
  
  
  • Substance Abuse and Mental Health Services Administration, (2020). Treatment for Suicidal Ideation, Self-harm, and Suicide Attempts Among SAMHSA Publication No. PEP20-06- 01-002 Rockville, MD: National Mental Health and Substance Use Policy Laboratory.
  • King, C. A., Arango, A., Kramer, A., et al. (2019). Association of the Youth-Nominated Support Team Intervention for Suicidal Adolescents with 11- to 14- Year Mortality Outcomes: Secondary Analysis of a Randomized Clinical JAMA Psychiatry, 76(5): 492-498.
  • Berk, S., Gallop, R., Asarnow, J.R., et al. (2022). Trajectories of Treatment Response and Nonresponse in Youth at High Risk for Suicide. J Am Acad Child Adolesc Psychiatry. Published online ahead of print. DOI: 10.1016/j.jaac.2022.01.010.
  • McCauley, , Berk, M. S., Asarnow, J. R., et al. (2018). Efficacy of Dialectical Behavioral Therapy for Adolescents at High Risk for Suicide. JAMA Psychiatry, 75(8): 777-785.
  • Asarnow, J.R., Hughes, J.L., Babeva, K.N., Sugar, C.A. (2017) Cognitive-behavioral family treatment for suicide attempt prevention: a randomized controlled J Am Acad Child Adolesc Psychiatry 56(6):506–514.
  • Kennard, B.D., Goldstein, T., Foxwell, A.A., et al. (2018) As Safe as Possible (ASAP): a brief app- supported inpatient intervention to prevent postdischarge suicidal behavior in hospitalized, suicidal Am J Psychiatry 175(9):864–872.
  • Czyz, E. K., King, C. A., & Biermann, B. J. (2019). Motivational Interviewing-Enhanced Safety Planning for Adolescents at High Suicide Risk: A Pilot Randomized Controlled Trial. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 48(2), 250–262.
  • Diamond, S., Wintersteen, M.B., Brown, G. K., et al. (2010) Attachment-based family therapy for adolescents with suicidal ideation: A randomized controlled trial. J Am Acad Child Adol Psychiatry, 49(2): 122-131.

Given this growing body of evidence that supports the validity, feasibility, and acceptability of suicide screening that can be paired with evidence-based interventions and support, along with the dire youth mental health and suicide crisis, we respectfully urge the Task Force to review the evidence further and consider aligning with Bright Futures and the AAP Blueprint for Youth Suicide Prevention in recommending routine suicide screening starting at age 12.

We also encourage the Task Force to expand the Practice Considerations section of the current recommendation statement, and in particular the Suggestions for Practice Regarding the I Statement section. We recommend including stronger language in this section to acknowledge the need to prevent youth suicide and the potentially critical benefit of universal screening as a method to identify at-risk youth whose risk would otherwise go undetected. We also recommend adding language acknowledging universal screening as an avenue toward equity, since Black and Hispanic youth show concerning trends in suicidal behavior and mortality, and implicit bias still deters clinicians from recognizing mental health distress in minoritized populations. Additionally, when clinicians have concerns regarding the patient, language should be included that emphasizes the existence of effective, validated screening instruments, the lack of harms associated with screenings, and the importance of evidence-informed care steps that are patient centered and culturally sensitive.

It has been well established by research that asking about suicidal thoughts does not cause harm.[5]^,[6]  We also know that screening for depression misses approximately 30% of youth who are experiencing thoughts of suicide or have made a suicide attempt, largely because depression isn’t the only risk factor for suicide, and the single suicide-related item in the most commonly used depression screening instrument (item #9 of the PHQ-9) often fails to identify individuals whose suicide risk is elevated.^7,8 Suicide is dynamic and complex, and stems from the combined effect of factors including mental and behavioral health conditions such as depression, anxiety, ADHD, psychosis, eating disorders, substance use, as well as current life stressors such as interpersonal conflict in the home, bullying, and trauma, among others. 

There has never been a more urgent time for implementing effective suicide prevention initiatives, and leading health policy initiatives are responding. Screening for suicide risk among youth is the first step in taking further supportive steps that have evidence for reducing suicide risk. These include brief "interventions" that can be feasibly done in a primary care setting: lethal means counseling, safety planning, education of parents and youth, and supportive ongoing follow up communication in addition to crisis resources and referrals.

We urge the Task Force to expand the report to provide appropriate considerations for primary care clinicians at this time of national crisis related to youth suicide and mental health. Thank you for your consideration.

Sincerely,

Bob Gebbia, CEO & Christine Yu Moutier, M.D., Chief Medical Officer

 cc: USPSTF Members

[1] Leeb, R. T., Bitsko, R. H., Radhakrishnan, L., Martinez, P., Njai, R., Holland, K. M. (2020). Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. Morbidity and Mortality Weekly Report, 69(45), 1675-1680. http://dx.doi.org/10.15585/mmwr.mm6945a3

[2] Children’s Hospital Association. (n.d.). Emergency Room Boarding of Kids in Mental Health Crisis. Retrieved from: https://www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_and_Advocacy/Key_Issues/Mental%20Health/2021/Boarding_fact_sheet_121421.pdf

[3] Children’s Hospital Association. (2021). COVID-19 and Children’s Mental Health. Retrieved from: https://www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_and_Advocacy/Key_Issues/Mental-Health/2021/covid_and_childrens_mental_health_factsheet_091721.pdf?la=en&hash=F201013848F9B9C97FAE16A89B01A38547C7C5C7

[4] Office of the U.S. Surgeon General. (2021). Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory. Retrieved from: https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf

[5] Gould, M. S., Marrocco, F. A., Kleinman, M., Thomas, J. G., Mostkoff, K., Cote, J., & Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. Jama, 293(13), 1635-1643.

[6] DeCou, C. R., & Schumann, M. E. (2018). On the iatrogenic risk of assessing suicidality: A meta‐analysis. Suicide and Life‐Threatening Behavior, 48(5), 531-543.

⁷ Kemper AR, Hostutler CA, Beck K, Fontanella CA, Bridge JA. Depression and Suicide-Risk Screening Results in Pediatric Primary Care. Pediatrics. 2021 Jul;148(1):e2021049999.

⁸ Horowitz LM, Mournet AM, Lanzillo E, He JP, Powell DS, Ross AM, Wharff EA, Bridge JA, Pao M. Screening Pediatric Medical Patients for Suicide Risk: Is Depression Screening Enough? J Adolesc Health. 2021 Jun;68(6):1183-1188.