The Centers for Disease Control and Prevention (CDC) reports that, except for a small decrease in 2019, suicide rates in the United States increased 33% over the past 3 decades. In total, 47,500 Americans died of suicide in 2019. Suicide is the second leading cause of death in the United States for people aged 10 to 34 years.1 Rates of suicidal ideation (SI) and behaviors in young people are equally concerning. The Youth Risk Behavior Surveillance System, conducted by the CDC in 2019, demonstrated that 18.8% of students considered suicide and 15.7% had a suicide plan in 12 months preceding the survey. In addition, 8.9% of students actually attempted suicide, with 2.5% requiring medical attention after an attempt.2
Owing to increasing rates of suicide, the Joint Commission (TJC) issued suicide prevention guidance for health care organizations through a Sentinel Event Alert (SEA) in 2016 and a National Patient Safety Goal (NPSG) in 2019.3,4 The SEA encouraged suicide risk screening in all health care settings using a standardized, brief, and evidence-based tool, while the NPSG focused on suicide prevention in general and psychiatric hospitals. TJC also provides resources for screening tools to health care organizations to implement suicide prevention programs.4 Universal suicide risk screening in the outpatient setting may represent an opportunity for suicide prevention.
Although studies have evaluated suicide risk screening in pediatric emergency departments,5,6 hospitals,7,8 and outpatient pediatric specialty clinics centers,9 the impact of universal suicide risk screening of children and adolescents with neurodevelopmental disabilities (NDD) has not been well studied. The feasibility and validity of standard suicide risk screening methods in the NDD population is unclear,10 although research has demonstrated increased risk of suicide in NDD populations.
The pediatric NDD population is heterogeneous, psychiatric comorbidities are common, and suicide risk is often under-recognized. Hardan and Sahl11 noted in a cohort of hospitalized children with both intellectual disability and psychiatric conditions, SI and attempts were noted in 20% of patients. In a study of children who died by suicide between ages 5 and 14 years, younger children (up to age 11 years) were more likely to be diagnosed with attention-deficit/hyperactivity disorder (ADHD) than older decedents.12 Reassuringly, Shoval et al.13 noted children receiving medication for ADHD were less at risk for suicidal behavior. Children with learning disabilities are at risk as well, with evidence that children with reading disabilities experience increased risk for suicidal thoughts and suicide attempts when compared with typical reading peers.14
Suicide risk in autism spectrum disorder (ASD) is significant. Hirvikoski et al.15 noted the risk of premature mortality from suicide in adults with ASD. Storch et al.16 noted SI in 11% of children with ASD. In a study by Mayes et al.,17 children with autism were compared with typically developing peers with and without depression. Mothers of the children with autism reported SI as a problem 14% of the time, 28 times more often than in typically developing children.
The purpose of this study was to describe the implementation of universal suicide risk screening in pediatric NDD clinics, analyze demographic and clinical characteristics of eligible patients, analyze factors that influenced participation in screenings, and describe clinical management of positive screenings.
Planning and Protocol
Our facility is a tertiary pediatric neurodevelopmental disabilities (NDD) and rehabilitation center serving individuals with a wide variety of NDD. This includes medical clinics focusing on learning disorders, autism, cerebral palsy, brain injury, spinal cord injury, neurological disorders, chronic pain, and other related disorders. An interdisciplinary task force, including pediatric medicine, child psychiatry, nursing, social work, and psychology, designed and implemented a suicide risk screening program for all medical clinics. All involved clinical staff received education in suicide prevention, diagnosis and management of suicidal ideation (SI), and the institutional screening protocol. Training sessions were led by study team members with experience in suicide prevention research and education. Use of standardized tools to assess suicide risk and guide safety plans was presented, including the Columbia-Suicide Severity Rating Scale18 and the Ask Suicide-Screening Questions (ASQ) toolkit's brief suicide safety assessment (BSSA).19 The use of these tools, in particular the ASQ BSSA, was encouraged, but not mandatory, for patients who screened positive for increased suicide risk. Information was provided in required lectures and in written format.
Implementation of universal suicide risk screening was initially met with concerns from some staff. Despite research to the contrary,20 some worried about iatrogenic risk for SI. Question and answer sessions were held to provide education regarding the blunt wording of the questions, address concerns of potential alienation of patients and caregivers, and discuss the validity of screening in children with NDD. There was a 1-month pilot in a subset of clinics. The purpose of the pilot was to identify workflow issues or educational needs before implementation. Additional staff educational meetings were held as needed to address questions, reinforce education, and ensure compliance with established procedures after the start of the protocol.
The “Ask Suicide-Screening Questions” (ASQ) tool was designed for pediatric medical patients and chosen as the screening tool based on ease of administration, screening administration time, and nonproprietary nature of the tool.5–7,19 Validation studies of the ASQ have demonstrated sensitivity between 96.7% and 96.9%, specificity between 87.6% and 91.1%, and negative predictive value between 99.7% and 99.8%.5,6
The ASQ consists of 4 suicide risk screening questions. A “yes” response to any of the questions was considered a positive screening. If patients answered “yes” to any of the 4 initial questions, patients were then asked the acuity question of “Are you having thoughts of killing yourself now?” An affirmative answer to this question was considered an acute positive screening and suggestive of active SI.
All patients aged 8 to 18 years who presented to a medical clinic were eligible for screening at each visit. See Table 1 for the list of participating clinics. There were no additional criteria for screening, including degree of cognitive or communication impairment if present. Although the ASQ is not validated below age 10 years, our workgroup chose to perform screenings starting at age 8 years, given that younger children may have unrecognized suicide risk. Children aged 8 to 12 years were screened with their parent or guardian present. Parents were able to answer questions on behalf of their child, although the ASQ does not have a parent version. Children older than 12 years were screened without a parent or guardian present, if approved by the parent, to encourage uninhibited responses. Patients, parents, and guardians could decline participation in the screening. Reasons for declined screenings were documented in the medical record.
Table 1. -
Response to Suicide Screening by Clinics
||Total Eligible Visits
|n (% of Total Eligible)
||n (% Eligible in Each Clinic)
||n (% of Screened in Each Clinic)
||n (% of Total Eligible)
|Autism and related disorders
|All surgery clinics
|Bone and osteogenesis imperfecta
|Spinal cord injury
A registered nurse performed screening during triage at each appointment. Before screening, nurses used a standard script that presented the purpose of screening, normalized the procedure, and assured confidentiality. If there were any concerns for self-harm or safety, however, parents were notified immediately and included in follow-up planning. The screening questions from ASQ were administered verbatim and verbally. No written material was used for patient self-report.
If a patient had a positive screening, appropriate medical staff members were notified. Further suicide risk assessment was performed by the physician, nurse practitioner, or a mental health professional (clinical social worker or psychologist). Management and follow-up treatment plans were based on the suicide risk assessment. Options for the follow-up included additional visits with the treating physician or nurse practitioner, referral to new outpatient mental health therapy services or psychiatry, follow-up with current mental health therapist or psychiatrist, referral to the local emergency department for evaluation, or referral for acute psychiatric care, either intensive day treatment or inpatient.
Data Analysis Procedures
A retrospective chart review was conducted to identify eligible patients who presented to participating clinics over the study period. Demographics and clinical data were extracted from the medical record. All eligible visits were separated into positive and negative screening groups through query of the medical record. Clinical documentation of each visit with a positive screening was manually reviewed by study team members. The chart review was conducted by 1 reviewer under close supervision of the principal investigator. Data reconciliation primarily involved documentation of response by clinicians to positive screenings. The principal investigator determined whether minimal criteria were met for documentation of suicide risk assessment and follow-up plans.
Univariate analyses were used to (1) describe rates of declined, positive, and negative screenings; (2) compare patient characteristics between declined and completed screenings; and (3) compare patient characteristics between positive and negative screenings. Associations between endorsed screening questions and patient characteristics among positive screenings were analyzed. Clinical dispositions after positive screenings were analyzed with descriptive statistics. STATA 15SE-6421 was used for all analyses. This study was approved by our local university's Institutional Review Board.
Data were collected during a 6-month study period from August 2017 to January 2018. There were 5260 eligible patient visits representing 2961 individual patients, with 893 (30.2%) individuals screened multiple times because of repeat visits. A total of 3854 (73.3%) screenings were completed. In total, 1406 (26.7%) of eligible visits did not complete screening because of declined participation. Parents or guardians answered questions from Ask Suicide-Screening Questions (ASQ) on behalf of their child in 701 (18%) of 3854 completed screenings.
Our sample included 3488 eligible visits by male patients (66.3%), 1770 female patients (33.7%), and 2 (0.04%) with unknown sex. There were no sex differences between those who participated in screening versus declined screening. The average age of all eligible patients was 11.9 years. The average age of those who participated in screening (12.1 years) was significantly older than those who declined participation (11.2 years) (odds ratio [OR] 0.89; confidence interval [CI] 0.87–0.91; p < 0.001).
The screened patients were predominantly male (n = 2,537, 65.8%) and White (n = 1,839, 47.7%). The sample included 1309 (34.0%) patients who identified as African-American, 172 (4.5%) Hispanic, 121 (3.1%) Asian, 7 (0.2%) American Indian or Alaska Native, and 406 (10.5%) with multiracial or unidentified race or ethnicity. The Asian patients were more likely to refuse screening (OR 1.9; CI 1.4–2.5; p < 0.033) than other races or ethnicities. The African-American patients were significantly less likely to refuse screening as compared with White patients (OR 0.9; CI 0.7–0.9; p = 0.033).
Of the 3854 screened visits, 261 (6.8%) were positive with at least 1 “yes.” Parents or guardians responded on behalf of their child with at least 1 “yes” in 20 of the 261 (7.7%) positive screenings. Male patients were less likely to screen positive than female patients (OR 0.7; CI 0.5–0.0.9; p = 0.002). The African-American patients were significantly less likely to screen positive than White patients (OR 0.5; CI 0.4–0.8; p < 0.001). Among positive screenings, 21 of 261 (8%) were completed by parents or guardians.
There were 1406 declined screenings with 1354 (96.3%) at the request of the parent or guardian. Only 52 visits (3.6%) documented a patient request to decline participation. The most common reason for declining screening was the patient's lack of cognitive ability to understand the questions (n = 580; 41.5%), unspecified reasons (n = 355; 25.2%), and lack of concern for suicidal thoughts or behaviors (n = 185; 13.2%). Less common reasons for declined screenings included concerns that it was inappropriate to ask about suicide (n = 117; 8.3%), patient was too young (n = 40; 2.8%), it would give the patient ideas about suicide (n = 29; 2.1%), screening was scary or distressing (n = 18; 1.3%), or for religious reasons (n = 5; 0.4%).
Table 1 summarizes screening results by specialty clinics. In some clinics, the rates of refusal were more than 50%. The lowest rates of refusal were in clinics for children suffering from traumatic stress, chronic pain, and concussion. The developmental pediatrics clinic had both a high screening compliance rate at 81.8% of eligible visits and a lower positive screening rate (5.4%) than the overall rate (6.8%). Among larger clinics, higher rates of positive screenings were noted in autism (12%), chronic pain (10.6%), and concussion (7.3%) clinics.
Table 2 describes positive answers to questions from ASQ questions. The most commonly endorsed question (54%) was “In the past few weeks, have you wished you were dead?” Non-White minorities were less likely to endorse “In the past week, have you been having thoughts about killing yourself?” (OR 0.5; CI 0.4–0.8; p = 0.002) but were just as likely as White patients to endorse all other questions. Male patients were less likely to endorse questions “In the past few weeks, have you wished you were dead?” (OR 0.6; CI 0.4–0.8; p = 0.001), “In the past few weeks, have you felt that you or your family would be better off if you were dead?” (OR 0.6; CI 0.4–0.9; p = 0.009), and “In the past week, have you been having thoughts about killing yourself?” (OR 0.6; CI 0.4–0.9; p = 0.006) compared with their female counterparts. Older patients were more likely to endorse “In the past few weeks, have you felt that you or your family would be better off if you were dead?” (OR 1.2; CI 1.1–1.3; p = 0.001) and “Have you ever tried to kill yourself?” (OR 1.1; CI 1.0–1.2; p = 0.015).
Table 2. -
Positive Responses to Ask Suicide-Screening Questions
|OR (95% CI, p)
||OR (95% CI, p)
||OR (95% CI, p)
|1. “In the past few weeks, have you wished you were dead?”
||1.0 (0.9, 1.1, 0.347)
||0.6, (0.4, 0.8, 0.001)
||0.7 (0.5, 1.0, 0.083)
|2. “In the past few weeks, have you felt that you or your family would be better off if you were dead?”
||1.2 (1.1, 1.3, <0.001)
||0.6 (0.4, 0.9, 0.009)
||0.6 (0.4, 1.0, 0.052)
|3. “In the past week, have you been having thoughts about killing yourself?”
||1.0 (0.9, 1.1, 0.224)
||0.6 (0.4, 0.9, 0.006)
||0.5 (0.4, 0.8, 0.002)
|4. “Have you ever tried to kill yourself?”
||1.1 (1.0, 1.2, 0.015)
||0.7 (0.5, 1.1, 0.121)
||0.8 (0.5, 1.1, 0.173)
|5. “Are you having thoughts of killing yourself now?”
||1.1 (0.9, 1.4, 0.274)
||0.7 (0.2, 2.1, 0.491)
||1.4 (0.5, 4.1, 0.550)
Total positive screenings = 261.
CI, confidence interval; OR, odds ratio.
Table 3 describes follow-up actions taken after positive screenings in general and specifically for affirmative answers to the acuity question. Clinicians documented addressing the positive screening in 202 of 261 (77.4%) visits. New psychotropic medications were started in less than 20% of visits with both acute and nonacute positive screenings. A follow-up appointment with the treating physician or nurse practitioner was scheduled in 240 of 261 (92.0%) visits. New referrals to psychiatry and mental health therapy occurred in 35 of 261 (13.4%) and 56 of 261 (21.5%) of visits, respectively. Overall, 72 of the 187 (38.5%) individuals who screened positive were connected to new outpatient mental health services. In patients who were followed before the visit by a psychiatrist or mental health therapist, referrals back for continued care were noted in 111 of 261 (42.5%) and 147 of 261 (56.3%) visits, respectively.
Table 3. -
Clinical Follow-Up to Positive Screenings
||Acute Positive Screenings
|Total positive screenings
|Positive screening addressed in clinical documentation
|Follow-up appointment scheduled
|New psychotropic medication initiated
|New referral to psychiatry
|New referral to mental health therapy
|Referred to current psychiatrist
|Referred to current mental health therapist
|Referral to acute psychiatric care
|Referred to emergency department
|Referred to psychiatric intensive day treatment
|Admitted to inpatient psychiatry
Acute positive screenings are affirmative responses to the acuity question “Are you having thoughts of killing yourself now?”
Regarding the acuity question, 13 of 14 (92.9%) visits with positive responses to the acuity question had follow-up plans documented. Eight of 14 patients (57.1%) were referred back to their established treating psychiatrists and therapists. No new referrals were made to outpatient psychiatry, whereas 3 of 14 (21.4%) received new referrals for outpatient mental health therapy.
Among the 261 positive screenings, 8 patients (3.1%) required acute psychiatric evaluation and care, 3 patients required evaluation in an emergency department, 3 were admitted to intensive outpatient psychiatry programs, and 2 were admitted for acute inpatient psychiatric treatment.
This study demonstrates that implementation of universal suicide risk screening in pediatric neurodevelopmental clinics was feasible. Owing to the optional nature of screening, our protocol identified some, but not necessarily all, children at increased risk for suicide. Ongoing education to parents and caregivers regarding suicide risk could increase future participation in screenings. Routine screening may help to destigmatize mental health issues in general, and suicide specifically, for patients, families, and staff.
Given that this study took place during the first 6 months of implementation, clinicians initially were not familiar with performing and documenting suicide risk assessments. Despite this, most of the visits with positive screenings had documentation of appropriate management and follow-up. As the study design was a retrospective chart review, it is impossible to know what actual suicide-related discussions occurred in the clinical setting. Documentation may underrepresent completion of further risk assessment in visits during which positive screenings were discussed but not documented. Without real-time data collection, true compliance is not clear. To increase awareness and compliance, clinicians who had visits without documented suicide risk assessment were identified and provided direct feedback and education. Ongoing monitoring of positive screenings remains in place to ensure for appropriate management and follow-up care.
Our rate of positive screenings (6.8%) was slightly lower compared with the rate (7.8%) in children universally screened with the Ask Suicide-Screening Questions (ASQ) in a pediatric emergency department (ED).6 In another pediatric ED study, rates of positive screenings for children presenting with nonpsychiatric complaints were 4%, lower than our overall rate.5 This variation in rates among youth with and without neurodevelopmental disabilities (NDD) may indicate true differences in suicide risk or cognitive impairments or reflect psychiatric comorbidities. It is unclear whether, and to what degree, patients with NDD had challenges understanding questions from ASQ. This potentially affected results and would benefit from the future study.
The high rate of declined participation in screening may have influenced the results. Caregivers frequently indicated their child was incapable of comprehending screening questions because of cognitive deficits. However, children with NDD may have unrecognized suicidal ideation (SI), especially those with comorbid psychiatric diagnoses. As noted previously, Hardan and Sahl11 found in their study of 90 children with mild-to-moderate ID and psychiatric diagnoses that the rate of SI was 20%. Another study of 233 children with a mean age of 10 years with psychiatric illness and borderline-to-moderate ID demonstrated an SI rate of 20%. Notably, children as young as age 4 years in this study reported SI or previous suicide attempts.22
Parents and caregivers of children with NDD may carry a bias toward not identifying SI. By contrast, in a study of caregivers for adults with ID, most caregivers (77%) reported they cared for individuals who displayed SI.23 Clinicians should provide anticipatory guidance and education regarding the risk of SI to parents and guardians of children with NDD.
There were no differences between sexes regarding participation, although the mean age of those declining screenings (11.2 years) was significantly less than those who participated (12.1 years). Consistent with suicide risk screenings performed both in ED and on inpatient pediatric settings,5,7 female patients screened positive more often than male patients in our study. Although our sample was predominately White and male, the African-American patients were less likely to refuse screening and less likely to screen positive compared with White patients. This is important, given data showing the suicide death rate in African-American youth is increasing faster than any other racial/ethnic group in the 5-year to 14-year age group.24
The autism clinic had a high rate (12%) of positive screenings. Children with autism spectrum disorder (ASD) may be more vulnerable to developing SI because of social isolation and bullying, along with psychiatric comorbidities. In a study of high school students, 22.7% of students with disabilities reported a previous suicide attempt, with ASD representing the second largest subgroup of children with disabilities.25 This finding is similar to data in the adult ASD literature, in which increased risk for suicidal thoughts and behaviors is well-documented.26,27
Two rehabilitation clinics, concussion and chronic pain, had higher positive screening rates compared with our overall institute rate. The concussion clinic had a positive screening rate of 7.3%. This supports research demonstrating increased novel psychiatric conditions, including suicidal thoughts and behaviors, after pediatric sports-related concussion.28 The chronic pain clinic had an even higher rate of positive screenings (10.6%). This may be due to the complex biopsychosocial pathophysiology that leads to chronic pain, including psychiatric comorbidities.29 Further study is warranted in all pediatric rehabilitation populations to identify additional factors that lead to variations in SI rates.
Finally, additional research is needed to determine whether universal suicide risk screening programs are effective in preventing future deaths by suicide in children. The predictive value for future suicide-related visits or death after a positive suicide risk screening in pediatric EDs has been demonstrated when youth are universally screened.6 Ballard et al.30 noted a sensitivity of 93% in predicting a subsequent return to the pediatric ED for suicide-related visits after a positive ASQ screening in psychiatric patients. However, it remains unclear whether suicide risk screening within the outpatient pediatric setting in general, and in the NDD population in particular, can predict and prevent future suicides.
The most important limitation of this study is lack of validation of the Ask Suicide-Screening Questions (ASQ) in children with neurodevelopmental disabilities (NDD). Many children in our clinics have intellectual disability, language deficits, or other cognitive issues. Some children may not understand the concept of suicide or the context of suicide-related questions. Further studies are planned in our clinics to validate the use of the ASQ in our clinical population.
We did not collect intelligence quotient or other functional data which could help assess the validity of the ASQ in children with NDD. Responses were analyzed in the context of the clinic attended, not by diagnoses, cognitive status, or function, which limits the true extent of NDD in the sample. A more in-depth analysis in future research of patients using these parameters could be informative. The single-site study design may have affected the generalizability of results because of sampling of ethnicity, race, and age and because of the effects of health care inequities and social determinants of health. For example, we did not collect data on whether languages other than English were spoken at the time of triage. It is unclear how many required an interpreter to complete the screening or whether they declined screening because of language issues. This may have influenced data.
Our study focused on immediate clinical responses to positive screenings and did not collect data on long-term outcomes of patients with positive suicide risk screenings. The outcome focused on risk assessment, mental health referral, and management of actively suicidal children. Further study of the longitudinal outcomes of children with NDD who screen positive could affect the identification of additional factors that increase the risk of suicidal behaviors.
Other limitations included the high rate of declined screenings and screenings answered by parents on behalf of the patient. Multiple informants in the screening process, including patient and caregivers, could help inform true suicide risk, which could be explored in future studies. There may be a role for proxy screening tools in the NDD population. Finally, because there were no in-person observations on visits, it was impossible to determine whether screenings were uniformly administered or the extent of undocumented further suicide risk assessments.
This study documents that it is feasible to implement universal suicide risk screening in youth with neurodevelopmental disabilities (NDD) in outpatient clinic settings. Screening of the NDD population is important because a 6.8% rate of positive screenings was established, similar to rates seen in neurotypical children. As other health care institutions implement universal suicide risk screening, it is important that children with NDD be screened for suicide risk and not be excluded from screening protocols. Early identification of suicide risk can help guide mental health interventions and hopefully prevent suicide attempts. Our research demonstrated that this is especially important in children with autism spectrum disorder along with children with NDD and psychiatric comorbidities. In addition, this study calls for more research into validation of the Ask Suicide-Screening Questions in the NDD population.
1. Suicide Prevention. Centers for Disease Control and Prevention Website. Available at: https://www.cdc.gov/suicide/facts/index.html
. Accessed February 10, 2021.
2. Youth Risk Behavior Surveillance System (YRBSS). Centers for Disease Control and Prevention Website. Available at: https://www.cdc.gov/healthyyouth/data/yrbs/index.htm
. Accessed September 13, 2020.
3. Sentinel Event Alert 56: Detecting and Treating Suicide Ideation in All Settings. The Joint Commission Website. Available at: https://www.jointcommission.org/sea_issue_56/
. Accessed September 25, 2019.
4. R3 Report Issue 18: National Patient Safety Goal for Suicide Prevention. The Joint Commission Website. Available at: https://www.jointcommission.org/en/standards/r3-report/r3-report-issue-18-national-patient-safety-goal-for-suicide-prevention
. Accessed April 14, 2020.
5. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166:1170–1176.
6. DeVylder JE, Ryan TC, Cwik M, et al. Assessment of selective and universal screening for suicide Risk in a Pediatric emergency department. JAMA Netw Open. 2019;2:e1914070.
7. Horowitz LM, Wharff EA, Mournet AM, et al. Validation and feasibility of the ASQ among pediatric medical and surgical Inpatients. Hosp Pediatr. 2020;10:750–757.
8. Latif F, Patel S, Badolato G, et al. Improving youth suicide risk screening and assessment in a pediatric hospital setting by using the Joint Commission Guidelines. Hosp Pediatr. 2020;10:884–892.
9. Lois BH, Urban TH, Wong C, et al. Integrating suicide risk screening into pediatric ambulatory subspecialty care. Pediatr Qual Saf. 2020;5:e310.
10. Ludi E, Ballard ED, Greenbaum R, et al. Suicide risk in youth with intellectual disabilities: the challenges of screening. J Dev Behav Pediatr. 2012;33:431–440.
11. Hardan A, Sahl R. Suicidal behavior in children and adolescents with developmental disorders. Res Dev Disabil. 1999;20:287–296.
12. Sheftall AH, Asti L, Horowitz LM, et al. Suicide in elementary school-aged children and early adolescents. Pediatrics. 2016;138:e20160436.
13. Shoval G, Visoki E, Moore TM, et al. Evaluation of attention-deficit/hyperactivity disorder medications, externalizing symptoms, and suicidality in children. JAMA Netw Open. 2021;4:e2111342.
14. Daniel SS, Walsh AK, Goldston DB, et al. Suicidality, school dropout, and reading problems among adolescents. J Learn Disabil. 2006;39:507–514.
15. Hirvikoski T, Mittendorfer-Rutz E, Boman M, et al. Premature mortality in autism
spectrum disorder. Br J Psychiatry. 2016;208:232–238.
16. Storch EA, Sulkowski ML, Nadeau J, et al. The phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with autism
spectrum disorders. J Autism
Dev Disord. 2013;43:2450–2459.
17. Mayes SD, Gorman AA, Hillwig-Garcia J, et al. Suicide ideation and attempts in children with autism
. Res Autism
Spectr Disord. 2013;7:109–119.
18. The Columbia Protocol for Healthcare and Other Community Settings. The Columbia Lighthouse Project. Available at: https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare/#filter=.general-use.english
. Accessed July 31, 2021.
19. Ask Suicide-Screening Questions (ASQ) Toolkit. National Institute of Mental Health. Available at: https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials
. Accessed July 31, 2021.
20. Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005;293:1635–1643.
21. StataCorp [Computer Program]. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC; 2017.
22. Walters AS, Barrett RP, Knapp LG, et al. Suicidal behavior in children and adolescents with mental retardation. Res Dev Disabil. 1995;16:85–96.
23. Wark S, McKay K, Ryan P, et al. Suicide amongst people with intellectual disability: an Australian online study of disability support staff experiences and perceptions. J Intellect Disabil Res. 2018;62:1–9.
24. Congresswoman Watson Coleman releases CBC youth suicide taskforce report. Available at: https://watsoncoleman.house.gov/newsroom/documentsingle.aspx?DocumentID=1619
. Published December 17, 2019. Accessed September 15, 2020.
25. Moses T. Suicide attempts among adolescents with self-reported disabilities. Child Psychiatry Hum Dev. 2018;49:420–433.
26. Dell'Osso L, Carpita B, Muti D, et al. Mood symptoms and suicidality across the autism
spectrum. Compr Psychiatry. 2019;91:34–38.
27. Hooijer AAT, Sizoo BB. Temperament and character as risk factor for suicide ideation and attempts in adults with autism
spectrum disorders. Autism
28. Ellis MJ, Ritchie LJ, Koltek M, et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr. 2015;16:709–718.
29. Vinall J, Pavlova M, Asmundson GJ, et al. Mental health comorbidities in pediatric chronic pain: a narrative review of epidemiology, models, neurobiological mechanisms and treatment. Children (Basel). 2016;3:40.
30. Ballard ED, Cwik M, Van Eck K, et al. Identification of at-risk youth by suicide screening in a pediatric emergency department. Prev Sci. 2017;18:174–182.