Suicide is one of the the leading causes of death among American youth, and was the second-leading cause of death for children aged 10-14 in 2022. Adolescents have similarly high risk, with suicide ranking in the top three causes of mortality (after accidents and homicide) among ages 15-19. Troublingly, the suicide rate in this age group increased by 52.5% from 2000 to 2021, and these statistics underscore the urgent need for better identification of at-risk youth.

Emergency departments (EDs), particularly pediatric EDs (PEDs), are often the first point of contact for at-risk youth. During the pandemic, mental health-related ED visits surged by 24-31% for children and adolescents compared to 2019, but current suicide risk screening in PEDs are inconsistent, often exclude younger children, and can require multiple, lengthy mental health surveys. EDs often struggle to properly assess youth presenting with self-harm and suicide, with most mental health problems going undetected. 

Typically, triage nurses or behavioral health clinicians administer standardized questionnaires such as the Columbia-Suicide Severity Rating Scale (C-SSRS) or brief screeners like the Ask Suicide-Screening Questions (ASQ). However, these traditional screening protocols were primarily developed and validated for adolescents and adults, not children under 12. Thus, a gap exists in our screening approach: there is no well-validated standard  for children in elementary grades. Younger kids with suicidal thoughts or emotional distress may be missed by protocols designed for older youth. Even for adolescents, common screeners focus narrowly on suicide risk and may not capture co-occurring mental health symptoms that elevate risk, such as depression or anxiety. This is the context in which the Kiddie-Computerized Adaptive Test (K-CAT®) has emerged.

A new study conducted by researchers at NYU Grossman School of Medicine and Virginia Commonwealth University examined the effectiveness of the K-CAT® in two high-volume PEDs. The K-CAT® rapidly screens for depression, anxiety, and suicidality in under 4 minutes using computerized adaptive testing (CAT) while offering high psychometric reliability. This study was designed to test whether the K-CAT® increased the identification of suicide risk over recommended screening protocols and whether the prevalence of moderate to severe depression and anxiety in PEDs warrants advocating for multi-problem screening. Compared to the C-SSRS, the K-CAT® identified significantly more youth at risk for suicide, especially among 7- to 11-year-olds, a group often excluded from standard screening. Recent data suggest that children as young as 7, particularly those with mental health concerns, should be screened for suicide risk, and the K-CAT® was evaluated to fill this need. 

Of 341 eligible youth, 241 (70%) completed the K-CAT® on a tablet during their ED visit, indicating good feasibility based on the uptake in a busy ED for a new electronic tool. Of 241 youth screened, 32.5% screened positive for at least one mental health domain, and 3.95% received a suicide warning—none of whom were identified via retrospective C-SSRS screening. In other words, the K-CAT® detected suicidal risk in nearly 4% of youths who otherwise would have been missed entirely by standard screening. 

Traditionally, screening for multiple mental health conditions could involve administering multiple instruments, which is unsustainable in high-volume emergency settings. The study also highlighted that electronic assessment is not only feasible and well-received, but youth often prefer them and may be more willing to disclose sensitive information electronically due to reduced perceived judgment. The K-CAT® can also be built into the electronic health record and allow for administration through a patient portal, limiting the burden of clinical staff and standardizing the screening process to eliminate human error and unintentional bias.

This study supports the feasibility and potential value of using the K-CAT® for universal, multi-problem MH screening in PEDs. In particular, it can be used for identifying issues beyond suicidality (e.g., depression/anxiety), and highlights gaps in existing age-based screening protocols. Using tools such as the K-CAT® can prompt earlier referrals to outpatient mental health care or pediatricians, potentially addressing issues before they escalate to crises. As mental health crises among youth continue to strain our healthcare system, innovative solutions such as the K-CAT® provide hope that we can better identify and support at-risk children before crises occur. 

For more information on this study and its implications for suicide prevention in pediatric emergency departments, please refer to the full research article, published in Pediatric Emergency Care.