Suicide Risk Screening in Pediatric Hospitals: Clinical Pathways to Address a Global Health Crisis
Open accessAbstract
Background Youth suicide is on the rise worldwide. Most suicide decedents received healthcare services in the year before killing themselves. Standardized workflows for suicide risk screening in pediatric hospitals using validated tools can help with timely and appropriate intervention, while attending to The Joint Commission Sentinel Event Alert 56.Objective Here we describe the first attempt to generate clinical pathways for patients presenting to pediatric emergency departments (EDs) and inpatient medical settings.Methods The workgroup reviewed available evidence and generated a series of steps to be taken to feasibly screen medical patients presenting to hospitals. When evidence was limited, expert consensus was used. A standardized, iterative approach was utilized to create clinical pathways. Stakeholders reviewed initial drafts. Feedback was incorporated into the final pathway.Results Clinical pathways were created for suicide risk screening in pediatric EDs and inpatient medical/surgical units. The pathway outlines a 3-tiered screening process utilizing the Ask Suicide-Screening Questions for initial screening, followed by a brief suicide safety assessment to determine if a full suicide risk assessment is warranted. This essential step helps conserve resources and decide upon appropriate interventions for each patient who screens positive. Detailed implementation guidelines along with scripts for provider training are included.Conclusion Youth suicide is a significant public health problem. Clinical pathways can empower hospital systems by providing a guide for feasible and effective suicide risk-screening implementation by using validated tools to identify patients at risk and apply appropriate interventions for those who screen positive. Outcomes assessment is essential to inform future iterations.
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Disposition based on screening alone can fail to respond appropriately to real suicide risk and result in inefficient use of resources.
“Once a patient screens positive for suicide risk, a follow-up assessment is a critical best practice, as disposition based on screening alone can fail to respond appropriately to real suicide risk and result in inefficient use of resources.”
From Suicide in young people: screening, risk assessment, and intervention (2023) · cites this paper as [73]
The SAFE-T has frequently been used in primary care training and practice, though it was not included as a suggested suicide risk assessment tool by the AACAP PaCC Workgroup.
“The SAFE-T has frequently been used in primary care training and practice, though was not included as a suggested suicide risk assessment tool by the American Academy of Child and Adolescent Psychiatry (AACAP) Pathways in Clinical Care (PaCC) Workgroup.50”
From Evidence-based youth suicide prevention and intervention in pediatric primary care settings. (2024) · cites this paper as [50]
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Pollak, O. H., Sheehan, A. E., Walsh, R. F. L., Stephenson, A. R., Zell, H., Mayes, J., Lawrence, H. R., Bettis, A. H., & Liu, R. T. (2024) · Clinical Psychology Review · doi:10.1016/j.cpr.2024.102464 · Cited by 11 · see citing works
Evidence-based youth suicide prevention and intervention in pediatric primary care settings.
Ruch, D. A., Hughes, J. L., Bridge, J. A., & Fontanella, C. A. (2024) · Pediatric Clinics of North America · doi:10.1016/j.pcl.2024.07.017 · Cited by 10 · see citing works
Cafferty, R., Ambroggio, L., Leonard, J. E., Schmidt, S. K., & Haasz, M. (2022) · Pediatric Emergency Care · doi:10.1097/pec.0000000000002753 · Cited by 10 · see citing works
Lightbody, T. K., Thull‐Freedman, J. D., Freedman, S. B., Wright, B. J., Finseth, N., Coulombe, A., Morrissette, M., DeGuerre, A., McConnell, S., Bozocea, K., et al. (2023) · Canadian Journal of Emergency Medicine · doi:10.1007/s43678-023-00476-4 · Cited by 10 · see citing works
The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies
Saidinejad, M., Duffy, S. J., Wallin, D., Hoffmann, J. A., Joseph, M. M., Uhlenbrock, J. S., Brown, K. M., Waseem, M., Snow, S. K., Andrew, M., et al. (2023) · Journal of Emergency Nursing · doi:10.1016/j.jen.2023.07.005 · Cited by 10 · see citing works
Firearm Safety Screening in the Pediatric Hospital Setting: A Quality Improvement Initiative
Oddo, E. R., Kumar, N., Andrews, A. L., & Kwon, S. (2023) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000689 · Cited by 10 · see citing works
Emerging Adults’ Attitudes and Beliefs About Suicide and Technology/Social Media
Keating, S. R., & Rudd-Arieta, M. (2021) · The Journal for Nurse Practitioners · doi:10.1016/j.nurpra.2021.04.010 · Cited by 10 · see citing works
Youth suicide risk screening in an outpatient child abuse clinic
Ngai, M., Delaney, K. R., Limandri, B. J., Dreves, K., Tipton, M. V., & Horowitz, L. M. (2021) · Journal of Child and Adolescent Psychiatric Nursing · doi:10.1111/jcap.12335 · Cited by 10 · see citing works
Self-citationAdvocacy to Address Emergent Pediatric Mental Health Care
Gonzalez, K., Patel, F., Cutchins, L. A., Kodish, I. M., & Uspal, N. G. (2020) · Clinical Pediatric Emergency Medicine · doi:10.1016/j.cpem.2020.100778 · Cited by 9 · see citing works
Asking Preadolescents About Suicide Is Not Associated With Increased Suicidal Thoughts
Hennefield, L., Luking, K. R., Tillman, R., Barch, D. M., Luby, J. L., & Thompson, R. J. (2026) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2025.03.025 · Cited by 8 · see citing works
“These fi ndings also highlight the importance of following up a positive screen with a brief suicide safety assessment 21,25,45 to better evaluate risk for suicide and to determine next steps.”
Measurement choices for youth suicidality
Busby, D. R., Hughes, J. L., Walters, M., Ihediwa, A., Adeniran, M., Goodman, L., & Mayes, T. L. (2025) · Child Psychiatry & Human Development · doi:10.1007/s10578-023-01627-5 · Cited by 8 · see citing works
The Urgent Need to Recognize and Reduce Risk of Suicide for Children in the Welfare System
Horowitz, L. M., Kahn, G. D., & Wilcox, H. C. (2021) · PEDIATRICS · doi:10.1542/peds.2020-043471 · Cited by 8 · see citing works
Self-citationScreening and Risk Algorithms for Detecting Pediatric Suicide Risk in the Emergency Department
Aseltine, R. H., Sacco, S. J., Rogers, S. C., Wang, F., Schwartz, H., & Chen, K. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.33505 · Cited by 7 · see citing works
Chen, Y., Kraus, S. W., Freeman, M. J., & Freeman, A. J. (2023) · Psychiatric Services · doi:10.1176/appi.ps.20220201 · Cited by 7 · see citing works
Rodante, D., Papávero, E. B., Ingratta, A. V., Gorrini, A., Ralli, E., Rodante, E. D., Arismendi, M., Lowry, N. J., Ryan, P. C., Jian-Ping, H., et al. (2023) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2023.11.001 · Cited by 7 · see citing works
Self-citationTipton, M. V., de Arruda-Colli, M. N. F., Bedoya, S. Z., Pao, M., & Wiener, L. S. (2020) · Journal of Psychosocial Oncology · doi:10.1080/07347332.2020.1856997 · Cited by 7 · see citing works
Self-citationEvaluating the Prevalence of Suicide Risk Screening Practices in Accredited Hospitals
Chitavi, S. O., Williams, S. C., Patrianakos, J. L., Schmaltz, S. P., Boudreaux, E. D., Ahmedani, B. K., Roaten, K., Comtois, K. A., Akkas, F., & Brown, G. K. (2025) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2025.01.010 · Cited by 6 · see citing works
Cervantes, P. E., Gibbons, R. D., Seag, D. E. M., Baroni, A., Li, A. D. R., & Horwitz, S. M. (2024) · Evidence-Based Practice in Child and Adolescent Mental Health · doi:10.1080/23794925.2024.2303778 · Cited by 6 · see citing works
Afzal, K. I., Cheema, A., Cheema, H., Mournet, A. M., Wei, A. X., Khalid, A., Merai, R., Pao, M., & Horowitz, L. M. (2024) · Cureus · doi:10.7759/cureus.65763 · Cited by 6 · see citing works
Self-citationCafferty, R., Klott, A. M., Dafoe, A., Glaros, C., Dorsey, B., Haasz, M., Anthony, B. J., & O’Leary, S. T. (2025) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2025.03.019 · Cited by 6 · see citing works
Suicide and Substance Use Disorder
Connery, H. S., Korte, F. M., & McHugh, R. K. (2020) · Psychiatric Annals · doi:10.3928/00485713-20200311-01 · Cited by 6 · see citing works
Youth Suicide, Mental Health, and Firearm Access—Time to Focus on Upstream Prevention
Horowitz, L. M., Campo, J. V., & Bridge, J. A. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.23985 · Cited by 5 · see citing works
Self-citationFrey, L. M., Venugopal, D., & Dev, V. S. (2024) · PLoS ONE · doi:10.1371/journal.pone.0311403 · Cited by 5 · see citing works
Cervantes, P. E., Tay, E. T., Knapp, K., Wiener, E., Seag, D. E. M., Richards-Rachlin, S., Baroni, A., & Horwitz, S. M. (2023) · Pediatric Emergency Care · doi:10.1097/pec.0000000000002999 · Cited by 5 · see citing works
Clinical Pathways Programs in Children’s Hospitals
Bakel, L. A., Waynik, I. Y., Starmer, A. J., Berkwitt, A. K., & Ziniel, S. I. (2024) · PEDIATRICS · doi:10.1542/peds.2023-065553 · Cited by 5 · see citing works
Intent, Substance, and Care: Characteristics of Adolescent Ingestion Hospitalizations
Titus, L. L., Stephany, A. M., Porada, K., & McFadden, V. C. (2021) · Hospital Pediatrics · doi:10.1542/hpeds.2020-0083 · Cited by 5 · see citing works
Mournet, A. M., Bal, V. H., & Kleiman, E. M. (2023) · Archives of Suicide Research · doi:10.1080/13811118.2023.2252027 · Cited by 5 · see citing works
Pediatric hospital screening for suicide risk in adolescents referred for maltreatment
Azzopardi, C., Greenblatt, A., Korczak, D. J., & Smith, T. D. (2020) · Children and Youth Services Review · doi:10.1016/j.childyouth.2020.105500 · Cited by 5 · see citing works
Polihronis, C., Ziebell, L., Cloutier, P., Radomski, A. D., Sundar, P. D., Leith, S., Stewart, J., & Cappelli, M. (2023) · Canadian Journal of Community Mental Health · doi:10.7870/cjcmh-2023-027 · Cited by 4 · see citing works
Mirick, R. G. (2023) · Journal of Teaching in Social Work · doi:10.1080/08841233.2023.2207090 · Cited by 3 · see citing works
Cafferty, R., Klott, A. M., Dafoe, A., Glaros, C., Dorsey, B., Haasz, M., Anthony, B. J., & O’Leary, S. T. (2025) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2025.04.022 · Cited by 3 · see citing works
Cafferty, R., Leonard, J. E., Gillette, R. A., Bagg, M., Haasz, M., O’Leary, S. T., & Ambroggio, L. (2025) · Pediatric Emergency Care · doi:10.1097/pec.0000000000003479 · Cited by 3 · see citing works
Cervantes, P. E., Richards-Rachlin, S., Seag, D. E. M., Conlon, G. R., Donnelly, L., Lee, M. S., Shalev, R. A., Tay, E. T., Knapp, K., Wiener, E., et al. (2025) · Journal of Developmental and Physical Disabilities · doi:10.1007/s10882-025-10006-y · Cited by 3 · see citing works
Feasibility and importance of universal suicide screening in a pediatric emergency department
Rogers, S. C., Sacco, S. J., Volz, K., Chenard, D., Borrup, K. T., Chen, K., & Aseltine, R. H. (2025) · PLoS ONE · doi:10.1371/journal.pone.0321934 · Cited by 3 · see citing works
Training Needs Assessment Survey in Pediatric Consultation-Liaison Psychiatry
Meadows, A. L., Brahmbhatt, K., Shaw, R. J., Lee, J., Malas, N., Fuchs, D. C., Kurtz, B. P., Mooneyham, G. C., Gangopadhyay, M., Plioplys, S., et al. (2022) · Academic Psychiatry · doi:10.1007/s40596-022-01587-3 · Cited by 3 · see citing works
Self-citationImplementing Suicide Risk Screening in a Virtual Addiction Clinic
Glasner, S. V., Wei, A. X., Ryan, P. C., Michero, D., Monico, L. B., Pielsticker, P., & Horowitz, L. M. (2023) · Community Mental Health Journal · doi:10.1007/s10597-023-01181-3 · Cited by 3 · see citing works
Self-citationImplementation of a Suicide Risk Screening Clinical Pathway in a Children's Hospital
Brahmbhatt, K., Devlin, G., Atigapramoj, N. S., Bekmezian, A., Park, C. Y., Han, T., Dentoni-Lasofsky, B., Mangurian, C. V., & Grupp‐Phelan, J. (2024) · Pediatric Emergency Care · doi:10.1097/pec.0000000000003180 · Cited by 3 · see citing works
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Detecting Suicide Risk Among Pediatric Patients: Screening, Clinical Pathways, and Care
Horowitz, L. M., Lowry, N. J., Shi, T., Merai, R., Pao, M., & Bridge, J. A. (2025) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-081423-021101 · Cited by 3 · see citing works
Self-citationKurtz, B. P., & Levins, B. H. (2022) · FOCUS The Journal of Lifelong Learning in Psychiatry · doi:10.1176/appi.focus.20220039 · Cited by 3 · see citing works
Self-citationChild Sexual Abuse and Suicide
Hornor, G., & Tucker, S. (2022) · Journal of Forensic Nursing · doi:10.1097/jfn.0000000000000394 · Cited by 3 · see citing works
Clifton, R. L., Beemer, K., Camacho, M., & Adrian, M. C. (2025) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2025.107945 · Cited by 2 · see citing works
Marufu, T. C., Kaltsa, A., Albelbisi, Z., Carter, T., Coad, J., Bolton, S. J., Breedon, P., Craven, M. P., Frost, K., Harbottle, A., et al. (2025) · Journal of Child Health Care · doi:10.1177/13674935251374808 · Cited by 2 · see citing works
Gait difference between children aged 9 to 12 with and without potential depressive mood
Chan, P. P. K., Chen, C., Ayache, H., Louie, L. H.-T., Lok, A. K. Y., Cheung, N., & Cheung, R. T. H. (2021) · Gait & Posture · doi:10.1016/j.gaitpost.2021.10.012 · Cited by 2 · see citing works
ASQ – скрининг суицидального риска у детей и подростков
Семёнова, Н. В. (2021) · Суицидология · doi:10.32878/suiciderus.21-12-02(43)-51-58 · Cited by 2 · see citing works
Characteristics of a Pediatric Emergency Psychiatric Telephone Triage Service
Cancilliere, M. K., Ramanathan, A., Hoffman, P. E., Jencks, J. W., Spirito, A., & Donise, K. R. (2022) · Pediatric Emergency Care · doi:10.1097/pec.0000000000002831 · Cited by 2 · see citing works
- Authors
- Brahmbhatt, K., Kurtz, B. P., Afzal, K. I., Giles, L. L., Kowal, E. D., Johnson, K. P., Lanzillo, E., Pao, M., Plioplys, S., & Horowitz, L. M.
- Affiliations
- University of California, San Francisco (US)
- Cincinnati Children's Hospital Medical Center (US)
- University of Chicago (US)
- University of Utah (US)
- Michigan State University (US)
- Oregon Health & Science University (US)
- National Institutes of Health (US)
- Northwestern University (US)
- Corresponding author
- Horowitz, Lisa M.
- Venue
- Psychosomatics
- Publisher
- Elsevier BV
- Published
- 2019-01
- Volume
- 60
- Issue
- 1
- Pages
- 1-9
- ISSN
- 0033-3182 (ISSN-L)
- PMC
- PMC7898193
- OpenAlex
- W2894354536
- Cited by
- 146
- References
- 26
- Citations by year
- 2026: 7 · 2025: 18 · 2024: 23 · 2023: 32 · 2022: 21 · 2021: 18 · 2020: 21 · 2019: 5 · 2018: 1
- FWCI
- 13.19
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Psychosomatics (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- American Academy of Child and Adolescent Psychiatry's 2017 Abramson Fund (ZIA MH002922-10)
- National Institutes of Health
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Injury Epidemiology and Prevention
- Keywords
- youth suicide, suicide risk screening, children's hospitals, care pathways, pediatric emergency department, suicide risk assessment, Ask Suicide-Screening Questions, suicide prevention, provider training, implementation guidelines
- MeSH terms
- Suicide Prevention, Adolescent, Emergency Service, Hospital, Hospitalization, Hospitals, Pediatric, Humans, Mass Screening, Psychiatry, Referral and Consultation, Global Health, Risk Assessment, Critical Pathways, Workflow
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