Improving Suicide Risk Screening for Autistic Youth
November 10, 2022
By: Sherri Alms
According to a report by the United Health Foundation released in early October, suicides among adolescents ages 15 to 19 jumped 29% over the previous decade, from 8.4 per 100,000 to 10.8 per 100,000. In March, the American Academy of Pediatrics issued new recommendations that call for pediatric health providers to screen all young people age 12 and older for suicide risk at least once a year. Universal screening is the practice of screening all patients for suicide risk, not just those who have a behavioral health concern or diagnosis.
However, as noted by 2021 OAR-funded researchers, Paige Cervantes, Ph.D., and Sarah Horwitz, Ph.D., autistic children and adolescents are often excluded from or not focused on in either the development of screening instruments or the evaluation of suicide screening efforts. Prior to beginning their OAR-funded study, the researchers, both in the Department of Child and Adolescent Psychiatry at the NYU Grossman School of Medicine, analyzed data from the National Emergency Department Sample, the largest database of emergency visits in the United States. They found that emergency department visits for suicidal thoughts and self-harm were both more common and increased more over time in autistic youth and youth with intellectual disabilities than in youth without these diagnoses.
The goals of their one-year study, Is Universal Suicide Screening in the ED Universally Effective? Considerations for Youth with ASD, were to:
The researchers conducted the study in the Children’s Comprehensive Psychiatric Emergency Program (CCPEP) in Bellevue Hospital, New York City, which serves a diverse patient population. The research team asked all eligible youth (a total of 218 autistic children and teens between the ages of 7 and 18) and caregivers (a total of 213) presenting to the CCPEP to complete a primary screening tool, the Kiddie-Computerized Adaptive Testing (K-CAT) scale, developed in 2020 to measure mental health symptoms, during all three phases of their study:
For their clinician education session, the researchers asked autistic youth with a history of suicidal thoughts or behaviors, their caregivers, autism specialty clinicians, and emergency department clinicians about challenges encountered when seeking and receiving mental health care or providing care to autistic children and adolescents at risk for suicide and about recommendations for improvement with a specific focus on suicide prevention practices in emergency department settings.
K-CAT screening: The researchers found that about 77% of all screened youth scored as at risk for suicide while over 80% of autistic and possibly autistic youth scored at risk. When they compared the K-CAT’s results to a commonly used suicide risk measure (the Ask Suicide-Screening Questions [ASQ]) and to clinician judgment across autistic/possibly autistic and non-autistic participants, the researchers found that agreement between the K-Cat and the ASQ was similar for autistic youth, with agreement on suicide risk in 90% of the cases, compared to 85% for the non-autistic youth. Agreement was lower when the K-CAT was compared to clinician evaluation at 54% in the autistic group and 60% in the non-autistic group. Across both groups, the K-CAT was more likely to estimate suicide risk at a higher level than clinicians, which is preferred for screening so that youth who are a suicide risk do not screen as not at risk.
At the same time, data collected from interviews with autistic youth, caregivers, and autism specialist clinicians suggested that the K-CAT will likely need to be modified so that it is more accurate. Specifically, more than 6% of the items used in K-CAT screening were identified as problematic.
Clinician confidence and competence: In their baseline survey of the participating clinicians, the researchers found that while the clinicians thought addressing suicide risk in autism is important and modifications to their care are important, less than half identified autism as a suicide risk factor. In addition, nearly half reported having little to very little training in the screening and management of suicide risk for autistic youth. Confidence ratings across clinical areas related to suicide prevention practices were significantly lower for autistic compared to non-autistic patients.
Following the training, clinician confidence scores in their ability to provide suicide-related care to autistic patients were significantly higher than before, particularly in the area of suicide risk assessment. Overall, clinician ratings of the feasibility of recommended strategies and the utility of provided implementation supports were high.
While researchers noted that the increase in clinician confidence following the training was promising, they will need to evaluate clinician implementation of these recommendations with patients directly.
Additionally, they noted in their final report that the CCPEP clinicians who took part in the study are mental health professionals with expertise in managing mental health crises. It is likely they would have more training in autism and would feel more comfortable addressing suicide risk across patient populations compared to providers in general emergency department settings. Because of that difference, the researchers plan to evaluate the training and support needs of emergency department care providers in general settings in order to provide the information and supports they need.
The researchers also plan to continue their work to develop suicide risk measures for autistic children and adolescents and adapt suicide risk intervention strategies to better fit the autistic population and to be feasible for non-specialized providers to deliver.
Sherri Alms is the freelance editor of The OARacle, a role she took on in 2007. She has been a freelance writer and editor for more than 20 years.