What is the best pediatric screen for self-harm (self-injurious behavior) urges?

Best Pediatric Screen for Self-Harm Urges

The Ask Suicide-Screening Questions (ASQ) is the best validated brief screening tool for detecting self-harm urges and suicide risk in pediatric populations, with a sensitivity of 96.9% and negative predictive value of 99.7% in medical/surgical patients. 1

Primary Screening Recommendation

The ASQ is a 4-question instrument that can be rapidly administered by non-mental health clinicians in any pediatric setting, including emergency departments and primary care offices. 1 The four critical domains assessed are:

• Current thoughts of being better off dead 1
• Current wish to die 1
• Current suicidal ideation 1
• Past suicide attempts 1

This tool demonstrates superior performance with a sensitivity of 96.9% (95% CI, 91.3-99.4), specificity of 87.6%, and negative predictive values of 99.7% for medical/surgical patients and 96.9% for psychiatric patients. 1

Alternative Validated Screening Tools

Risk of Suicide Questionnaire (RSQ)

The RSQ is another brief 4-item screening tool that achieves a sensitivity of 0.98 and negative predictive value of 0.97 when assessing current suicidal behavior, past suicidal ideation, past self-destructive behavior, and current stressors. 2 This tool was specifically developed for pediatric emergency department triage nurses and can accurately detect suicidality in children and adolescents. 2

Columbia-Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is a more comprehensive tool that has been extensively researched in pediatric emergency departments, though it requires more time to administer than the ASQ or RSQ. 3

Depression Screening Context

For broader mental health screening that includes self-harm risk, the PHQ-9 should be used starting at age 12 years, as recommended by the USPSTF and American Academy of Pediatrics. 4

The PHQ-9 has:

• Sensitivity of 89.5% and specificity of 77.5% at a cutoff score of 11 for detecting major depressive disorder 4
• Item 9 specifically assesses thoughts of self-harm, requiring immediate referral if positive 4
• Validation in adolescent primary care populations aged 12-18 years 5

Implementation Strategy

In Emergency Department Settings

• Screen all pediatric patients aged 10-21 years, regardless of presenting complaint 1
• The ASQ identifies 53% of at-risk patients who do not present with suicide-related complaints 6
• Patients screening positive are more likely to be male, African American, and have externalizing behavior diagnoses 6
• The ASQ demonstrates 93% sensitivity for predicting return ED visits with suicide-related complaints within 6 months 6

In Primary Care Settings

• Universal depression screening with PHQ-9 should begin at age 12 years and continue through age 18 years 4
• Direct questioning about suicidal ideation should be embedded within depression symptom assessment: "Have you ever thought about killing yourself or wished you were dead?" 5
• Follow immediately with: "Have you ever done anything on purpose to hurt or kill yourself?" 5
• Self-administered scales can be useful because adolescents may disclose suicidality on self-report that they deny in person 5

Critical Pitfalls to Avoid

Never screen without having a clear protocol for managing positive screens - screening alone without intervention does not improve outcomes. 4

Do not assume absence of current suicidal ideation means low risk - if none of the factors that led to a previous attempt have changed, the patient remains at elevated risk. 5

Do not dismiss adolescents who "joke about suicide" - they may be asking for help the only way they can. 5

Recognize that irritability, not sadness, may be the primary manifestation of depression in adolescents - look for cranky mood, oppositional behavior, and loss of interest in previously enjoyed activities. 5

Age-Specific Considerations

• The ASQ has been validated in patients as young as 10 years old 1
• The K-CAT, a newer electronic screening tool, identifies suicide risk in children as young as 7 years, with 62.5% of identified youth being female and 33.3% being ages 7-11 years 7
• No screening studies included children younger than age 11 years in USPSTF evidence reviews for depression screening 5

Prevalence Data to Guide Screening

When universal screening is applied to all pediatric ED patients, approximately one-fifth screen positive for suicide risk. 3 When applied only to psychiatric patients, over half screen positive. 3 This underscores the critical importance of universal screening rather than selective screening based on presenting complaint. 6