Suicide Screening Reveals Alarming Trend in Cook Children’s Emergency Department

Seventeen in a series.

Along with the physical illnesses and injuries treated at the Cook Children’s emergency department (ED), a standard part of care includes a questionnaire that flags possible suicide risk.

Every patient ages 8 and older in Cook Children’s ED gets screened in a process that aims to proactively identify kids and teens who might be inclined to harm themselves. Much like more familiar vital signs -- temperature or heart rate, for example -- the screening for suicide takes a pulse on the patient’s emotional well-being.

“If a child arrived to the emergency room with a fever or a blood pressure problem, we would do lab work or various tests to search for the cause of these symptoms,” said psychiatry nurse case manager Melody Hackfeld, “With mental health issues, screening for suicide and asking about sadness and worries is how you determine there is a concern that needs to be addressed.” 

Numbers reveal an alarming trend: through July of this year, 261 patients required hospitalized medical stabilization at Cook Children’s due to suicide attempts. That compares to 143 patients hospitalized following suicide attempts in the first seven months of 2020. These statistics don’t include the attempted suicides in which the patient goes straight from the emergency room into psychiatric inpatient care.

Vigilance to prevent youth suicide takes on even greater urgency given the reported rise in anxiety and depression during the COVID-19 pandemic. In response, Cook Children’s has launched the Joy Campaign communications initiative as a way to spotlight areas of help and reasons for hope. The good news in this story? More kids who speak up. Earlier detection of suicidal tendencies. A quicker path to treatment.

A child or teen who arrives in the emergency department with a broken arm, for instance, or a severe case of the flu might also suffer from unexpressed suicidal ideas. By routinely asking a few brief questions in the ED, Cook Children’s works to detect any patients experiencing thoughts about harming themselves. The preemptive strategy uses two key components… screening and assessment.

“The emergency room staff lets them know that in addition to being worried about your physical health, we want to know more about your emotional health, and if you’re having any sadness or worries,” Hackfeld said. “You’d be surprised with how many kids just open the floodgates” with honest answers and relief.

The National Institute of Mental Health developed the Ask Suicide-Screening Questions (ASQ) tool, which Cook Children’s uses. Nurses are trained to administer a five-part questionnaire:

1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself?
5. Are you having thoughts of killing yourself right now?

A “yes” answer to any of the five parts results in what’s called a positive ASQ, which leads to a closer assessment by the behavioral intake staff at Cook Children’s. After assessment, the range of recommendations can span from counseling to hospitalization, depending on the warning signs that surface when more in-depth questions are asked.

Experts describe the ASQ as a short, simple, valid and evidence-based method for identifying a suicidal inclination. Let’s take a closer look at how and why it fits into Cook Children’s delivery of emergency medical care.

Step 1: Screening

Patients fall into two categories. Those arriving with behavioral complaints (such as anxiety, self-harm, aggression, intentional ingestions, suicidal/homicidal ideation) are screened in the triage bay. Patients with nonbehavioral complaints (physical ailments) go through triage to be medically stabilized first. Later, during their secondary triage in the patient care rooms, the nurses screen the nonbehavioral patients. 

When Cook Children’s ED implemented suicide screening in 2017, Hackfeld and others worked to develop an educational video and computer-based training that incorporate scripts and scenarios to make the nurses more comfortable raising the topic.

“Some nurses thought if you asked about suicide it would give the child the thought, but research shows that that’s not true,” she said.

Nurses at Cook Children’s preface the conversation by asking “Do you struggle with sadness or worry?” An affirmative answer to that segue question doesn’t necessarily indicate suicide risk. But the discharge staff can provide those patients with take-home resources to help manage the sadness and worry.

ED nurse manager Kara Dorman tracks the number of nonbehavioral patients who answer at least one “yes” on the ASQ, requiring further evaluation. That number climbed from 18 patients (1.1% of the total screened) in March 2020, to 64 patients (3.4% of the total screened) in March 2021. Meanwhile, the patients who reported feeling sad or worried rose from 9.8% to 16.8%.

“Had ED staff not utilized the screening tool, then it is highly likely that no one would have known these children were struggling mentally or having suicidal thoughts,” Dorman said.

She points out that the nurses are trained to make eye contact, pay attention to facial expressions, and listen to tone of voice so they don’t miss any nonverbal cues during the screening. One challenge, she said, is establishing a good nurse-patient rapport in the ED within a short amount of time.

Step 2: Assessment

When a patient answers “yes” to one or more of the ASQ questions, the Cook Children’s intake team gets called in. The goal is to determine the degree of suicide risk, and the right course to follow next.

Phillip Breedlove, intake manager, explained that the assessment process dives deeper into the patient’s mental state. Breedlove and his team need more information in order to recommend either outpatient referral, immediate inpatient care, or something in between. The assessment typically starts with easy-to-answer questions.

‘’’So tell me, you're 10 years old, right? OK, good. I had to check that. And tell me what school do you go to and what grade are you in and how do you like school? What's your favorite subject? How are you doing in school?’ You start with that,” Breedlove said. “And then like, ‘How's your appetite? Have you been eating OK lately?’ You get progressively more personal.”  

One tool used is the Columbia-Suicide Severity Rating Scale, a checklist that covers various behaviors and the intensity/duration of suicidal thinking. Responses help the intake staff to weigh the risk factors versus the protective factors when assessing what type of treatment is needed, and how soon. Risk factors include feelings of hopelessness, agitation, previous self-injury, or a specific intent to attempt suicide. Protective factors include supportive friends and family, engagement in school, and strong religious beliefs.

Breedlove said patients with suicidal tendencies have become increasingly younger during his 22 years working at Cook Children’s. The cutoff for suicide screening in the ED used to be age 10. Breedlove said age 8 isn’t too young now, especially during the COVID-19 pandemic.

“The younger ones tend to be more in that angry, upset and impulsive category, and the older ones maybe tend to be thinking it out. They're pondering it. They're mulling over ways to harm themselves. It can be an impulsive act with them as well, but a lot of times you see the impulsivity more clearly with those younger kids,” he said. “I know anecdotally that a growing number of those sad, morose children with suicidal thinking is driven by a greater degree of hopelessness than in past years.”

Breedlove predicted an uptick in positive ASQ screens when school returns to in-person learning in the fall. He advocates for more frequent dialogue about suicide -- in homes and in every medical setting. The emergency department can be an especially opportune venue for preventing suicide in kids who don’t see a pediatrician regularly. Just a few questions and follow-up assessment can uncover a potential problem that might otherwise go unnoticed, Breedlove said.

Assessment can be a therapeutic process for the children or teens and their parents when the outcome leads to resources for help. Patients frequently thank the intake staff for taking the time to gather more background that clarifies the status of their mental health, he said.