Assessment of Suicidal Risk in Children and Adolescents with Autism Spectrum Disorder Presenting to a Pediatric Emergency Department

Background: Assessment of suicidal risk in children and adolescents with autism spectrum disorders (ASD) is a challenge due to their limited verbal and communicational skills. The existing body of literature mainly focuses on youth with ASD in community and hospital settings. Results indicate a higher rate of suicidal ideation in youth with ASD compared to control subjects. Potential risk factors for suicidality in this population include the absence of intellectual disability, a history of trauma, and the presence of co-morbid psychiatric disorders. Research on assessment of suicidal risk among children and adolescents with ASD presenting to the emergency department (ED)is scarce. Given the high rates of ED use in youth with ASD and the challenges with eliciting suicidality, developing methods to assess suicidal ideation in ED settings is critical in order to determine the most safe disposition plan (Kalb et al., 2012).

Objectives:

1. To compare the efficacy of the Ask Suicide Screening Questionnaire (ASQ) versus general screening at triage when assessing suicidal risk in children and adolescents with ASD in the ED setting.

2. To analyze the primary concerns and associated characteristics of children and adolescents with ASD who reported suicidal ideation.

Methods: Participants included 104 children and adolescents with ASD who presented to the ED of a major academic medical center. Participants were screened for suicidal risk through general questioning at triage and using the ASQ questionnaire. The ASQ is a 4-item suicide screening instrument that can be administered to patients in the ED for psychiatric or non-psychiatric reasons by nurses regardless of psychiatric training (Horowitz, et al., 2012). Participants who presented with psychiatric or behavioral complaints were screened more consistently than those with medical chief complaints. A chart review was conducted for 21 among 31 ASD youth who screened positive for suicidality with the ASQ screen (data for 10 participants were unavailable).

Results: Twelve children with ASD were identified as experiencing suicidal ideation on general screening at triage where as 31 children screened positive for suicide by the ASQ questionnaire, indicating that the ASQ picked up 19 additional cases of suicidality among this group. Among the 21 children with ASD and suicidal ideation according to the ASQ who were studied in detail, 12 (57%) reported previous attempts to hurt themselves. Nine (42%) were identified as a suicidal risk only by the ASQ questionnaire and were missed during general risk assessment at triage. Among them, six (33%) patients presented to the ED with a chief concern of aggression and 3(14%) presented with psychosis. The most common psychiatric diagnosis in youth with ASD were anxiety (n=11, 52%), ADHD/ODD (n=9, 42%) and mood disorders (n=8, 38%). Precipitants for suicidal ideation included limit setting, bullying, and conflicts at school or with peers.

Conclusions: Brief suicide screening instruments such as the ASQ appear to be effective in assess suicide risk in children and adolescent with ASD who present to the ED. Further research is needed to identify specific risk factors and clinical determinants that characterize suicidal behaviors in children and adolescents with ASD.