The study analyzed emergency department visits among children ages 5 to 17 who received a primary mental health diagnosis, using the Nationwide Emergency Department Sample database. In total, the analysis captured more than 5 million emergency visits for mental health concerns by U.S. children over the six-year study window, making it one of the most comprehensive portraits to date of how pediatric mental health crises flow through the American emergency care system. All pediatric mental health-related emergency visits increased by 24 percent during the study period, but suicide-related visits climbed nearly three times faster, rising 74 percent.

The diagnostic breakdown reveals where the burden is concentrated. The most frequent mental health diagnosis groups were suicide or self-injury, accounting for 24 percent of visits, and depressive disorders, accounting for 23 percent. Together, these two categories made up nearly half of all pediatric mental health emergency presentations, underscoring that suicidal thoughts and self-harm have become the single most common reason children arrive at emergency departments in psychological crisis. For clinicians and health systems, the trend signals a shifting caseload that many facilities were never designed to handle.

Perhaps the most striking structural finding concerns where these visits occur. About half of suicide-related emergency visits, and half of all children’s mental health emergency visits, took place in hospitals with lower pediatric volume, defined as fewer than 10,000 pediatric visits annually. A child experiencing a mental health crisis may arrive at any emergency department, the study authors noted, and many of these community hospitals are simply not prepared to care for children with acute mental health needs. Unlike large freestanding children’s hospitals, these facilities often lack dedicated psychiatric staff, child-specific protocols, and inpatient mental health beds.

The consequences of that gap are measurable. At emergency departments with the lowest pediatric volume, close to 30 percent of children seen for mental health conditions had to be transferred to other hospitals to receive definitive care. Such transfers are far from benign. Dr. Jennifer Hoffmann, senior author of the study and assistant professor of pediatric emergency medicine and medical social sciences at Feinberg, described the toll that waiting for a transfer imposes on families. Transfer to another hospital for pediatric mental health care often means a prolonged wait in the emergency department, sometimes lasting days, she said, increasing the burden on children and their families. During that interval, children in crisis may remain in crowded emergency settings without specialized psychiatric supervision.

Hoffmann emphasized that practical resources already exist to narrow this gap. Emergency departments across the country can access the New England Regional Behavioral Health Toolkit, as well as the National Pediatric Readiness Project, both of which offer free, evidence-based guidance for improving care for children, including youth with mental and behavioral health conditions. Toolkits are readily available to help emergency departments care for children with mental health needs, especially while kids wait for a transfer to another facility, she said. The hope is that better preparation at the point of first contact can stabilize children faster, shorten stays, and reduce the cascading stress that prolonged emergency boarding creates for young patients and their caregivers.

The study also surfaced significant disparities in where different groups of children receive care. Indigenous children were more likely to arrive at emergency departments with lower pediatric volume, meaning they are disproportionately likely to encounter facilities with fewer pediatric mental health resources. Youth with substance use concerns were also seen more often at lower-volume emergency departments. These patterns suggest that the children who already face elevated risks and structural barriers to care are, in many cases, being treated in the settings least equipped to meet their needs, compounding existing inequities in youth mental health outcomes.

Lead author Dr. Audrey Brewer, assistant professor of advanced pediatrics and primary care at Feinberg and a pediatrician and researcher at Lurie Children’s, argued that the findings demand a system-wide response rather than isolated fixes. Our findings underscore the need to equip every emergency department, not only large pediatric centers, with tools and resources to provide evidence-based mental health care, she said. Strengthening mental and behavioral health capacity across all emergency care settings is essential to ensuring children receive timely, effective and equitable care. In practice, Brewer said, that means all emergency departments need additional training and access to pediatric mental health professionals, whether onsite or via telehealth, as well as reliable linkage to follow-up care after discharge.

Brewer also called for a fundamental change in screening practice. Every emergency department, she said, should offer universal suicide screening for children, regardless of whether they arrive with a mental health concern, since suicidal thoughts may be present even when the chief complaint is a physical injury or illness. When concerns are identified, emergency departments should provide families with a clear plan to help keep their child safe at home, including means restriction and follow-up arrangements. Universal screening represents a low-cost intervention that could identify risk in children who would otherwise slip through unnoticed, but it requires training, standardized tools, and workflows that many smaller departments currently lack.

Beyond the emergency department itself, the authors pointed to the need for interventions designed for the full diversity of the pediatric population. To improve care, emergency department-based mental health interventions need to be developed and tested for children of color, since many have not been studied in diverse populations, Brewer said. Delivering culturally responsive, evidence-based interventions for children in the community and in outpatient primary care settings can help to potentially lessen emergency department reliance for mental health care and may help reduce disparities in youth mental health outcomes. As suicide-related emergency visits continue their steep climb, the study makes clear that the response cannot rest solely with a handful of specialized children’s hospitals; it must reach every emergency room in the country where a child in crisis might walk through the door.

Subject of Research: Pediatric suicide-related emergency department visits and emergency care capacity in the United States

Article Title: Children’s suicide-related emergency visits spiked by 74% in the US between 2016-2022

Article References: Children’s suicide-related emergency visits spiked by 74% in the US between 2016-2022. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: suicide-related visits, pediatric mental health, emergency department, children, Northwestern University, Lurie Children's Hospital, Annals of Emergency Medicine, suicide screening, health disparities, hospital transfers, pediatric readiness, youth mental health crisis

The ASQ itself is deceptively simple. It consists of four yes-or-no questions that ask whether the person wishes they were dead, feels that they or their family would be better off if they were dead, has thoughts of killing themselves, and, if the answer to any of the previous questions is yes, whether they have a plan. A fifth, non-scoring question asks whether the person would like help. Because it requires no special equipment, no lengthy training, and no psychiatric expertise to administer, the ASQ was designed to be used in emergency departments, primary care clinics, and any other medical setting where patients at risk might otherwise slip through unnoticed. The instrument has been validated in multiple languages and populations around the world, but until this study it had never been formally tested in the Malay language, which is spoken by the majority of Malaysia’s population of more than thirty million people. That gap mattered, because Malaysia sits in a region where suicide rates are underreported and mental health resources are stretched thin.

Translating a suicide screening tool is not as straightforward as swapping words between languages. Questions about death and self-harm are culturally loaded, and phrasing that sounds natural in English can become stilted, ambiguous, or even offensive when rendered literally in another tongue. The research team, led by Yu Xiang Chew and Lai Fong Chan of Universiti Kebangsaan Malaysia, with contributions from Lisa M. Horowitz of the University of Colorado School of Medicine and Children’s Hospital Colorado, one of the original developers of the ASQ, used a rigorous forward-backward translation process. In this approach, one translator converts the instrument from English into Malay, and a second, independent translator converts it back into English without seeing the original. Discrepancies between the back-translated version and the source text reveal ambiguities or distortions in the Malay wording, which the team then refined iteratively. They also assessed face validity, checking whether the questions appeared to measure what they were intended to measure, and content validity, ensuring that all essential dimensions of suicide risk were preserved in the new version.

Once the Malay ASQ was finalized, the researchers put it to the test in a real clinical environment. Their sample comprised 133 psychiatric patients, both inpatients and outpatients, aged between 19 and 70 years, with a mean age of 36.1 years. Nearly three-quarters of the participants, 73.7 percent, were female, and 77.4 percent were ethnically Malay, making the cohort representative of the population for whom the translated tool is intended. The study used a blinded, sequential design that strengthens confidence in the results. First, trained medical students administered the Malay ASQ to each participant. Then, separately, psychiatry medical officers conducted a clinical interview guided by the Brief Suicide Safety Assessment, or BSSA, a structured evaluation widely regarded as a robust reference standard for determining suicide risk. Crucially, the officers conducting the BSSA were blinded to the ASQ results, so their clinical judgments could not be influenced by the screening scores, and vice versa.

The statistical results paint a picture of a screening tool that performs remarkably well where it matters most. Sensitivity, the proportion of truly at-risk patients correctly identified by the screen, came in at 98.3 percent, meaning only a small handful of genuinely endangered individuals would have been missed. Specificity, the proportion of safe patients correctly cleared, was 65.3 percent, which is moderate and means the tool produces a fair number of false positives. The positive predictive value, the likelihood that a positive screen reflects true risk, was 68.7 percent, while the negative predictive value reached 98.0 percent. Overall accuracy was 79.7 percent, and agreement between the ASQ and the clinical interview was moderate, with a Cohen’s kappa of 0.606. In screening contexts, this trade-off is exactly what clinicians want: a tool that errs on the side of caution, catching nearly everyone at risk even at the cost of flagging some patients who ultimately prove safe on fuller evaluation.

Receiver Operating Characteristic analysis, the standard method for quantifying a diagnostic test’s discriminative ability, added further weight to the findings. The area under the curve, or AUC, was 0.818 with a 95 percent confidence interval of 0.745 to 0.891, statistically significant at p less than 0.001. An AUC of 0.8 is conventionally interpreted as good discriminative validity, indicating that the Malay ASQ distinguishes between at-risk and not-at-risk patients far better than chance. For context, a perfect test would score 1.0 and a useless one 0.5, so a value above 0.8 for a four-question instrument administered in under a minute is a strong result. The study also found an interesting demographic signal: patients who screened positive on the ASQ were significantly younger than those who screened negative, with a mean age of 33.14 years compared with 41.06 years, a difference that was statistically significant at p less than 0.001. This aligns with broader epidemiological evidence that younger psychiatric patients often carry elevated suicide risk.

Why does this validation matter beyond Malaysia? The global burden of suicide falls disproportionately on low- and middle-income countries, where the majority of the world’s suicides occur, yet where systematic screening programs are rare and validated instruments in local languages are scarcer still. Many health systems in these settings rely on clinical intuition alone, which research has repeatedly shown to be unreliable, since patients rarely volunteer suicidal thoughts without being asked directly. A validated, free, rapid screening tool in the local language removes one of the biggest practical barriers to universal suicide risk screening. The Malay ASQ gives Malaysian clinicians, and potentially clinicians across the Malay-speaking world, a culturally relevant instrument that can be embedded into routine intake procedures in emergency departments, general medical wards, and psychiatric clinics alike, enabling early identification and timely management of at-risk patients before a crisis occurs.

The study’s design also offers a template for how validation research should be conducted in multilingual settings. By combining a careful forward-backward translation with face and content validity assessment, and then testing the instrument against a blinded gold-standard interview in a real patient population, the team followed best practices in cross-cultural psychometrics. The choice of the Brief Suicide Safety Assessment as the reference standard is particularly notable, because it reflects actual clinical decision-making rather than a purely academic classification. The research was funded by the Fundamental Grant for Faculty of Medicine at Universiti Kebangsaan Malaysia, and the article is open access, meaning clinicians and researchers anywhere can consult the full methodology and adapt the approach for their own languages and populations.

There are, of course, limits to what any single validation study can establish. The sample of 133 patients, while adequate for the statistical analyses performed, came from a single Malaysian psychiatric service, and the predominantly female and Malay composition may not generalize perfectly to other demographic groups or to non-psychiatric medical settings such as emergency departments, where the ASQ is often deployed. The moderate specificity of 65.3 percent also means that health systems adopting the tool must be prepared to conduct follow-up assessments on a substantial share of positive screens, which requires trained personnel and time. Still, the authors conclude that the Malay ASQ is a valid and reliable screening instrument for detecting suicide risk among psychiatric patients, and their evidence supports its use as a practical, culturally relevant tool for early identification in Malaysian settings.

The broader takeaway is a hopeful one for global mental health. Suicide is largely preventable when risk is recognized in time, and the bottleneck has rarely been treatment; it has been detection. Instruments like the ASQ, now shown to survive translation into Malay with their accuracy intact, demonstrate that effective screening does not need to be expensive, lengthy, or technologically sophisticated. Four short questions, asked with care in a patient’s own language, can surface hidden danger and open the door to help. As more health systems in resource-constrained settings adopt validated local-language screening, the invisible fraction of at-risk patients who currently go unnoticed may finally begin to shrink.

Subject of Research: Validation of the Malay-language Ask Suicide-Screening Questions for detecting suicide risk in Malaysian psychiatric patients

Article Title: Concurrent validity and screening accuracy of the Malay Ask Suicide-Screening Questions (ASQ) among a Malaysian psychiatric sample

Article References: Chew, Y. X., Vejayan, A., Lam, C. B. Y., Mokhsain, S. M. S., Ibrahim, Z., Mohd Daud, T. I., Siau, C. S., Tan, Y. K., Mohd Fauzi, M. F. F., Rahman, N. A. A., Uyub, S., Yusoff Azli Shah, S. M., Manocha, S. K., Horowitz, L. M., & Chan, L. F. (2026). Concurrent validity and screening accuracy of the Malay Ask Suicide-Screening Questions (ASQ) among a Malaysian psychiatric sample. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08709-3

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08709-3

Keywords: suicide screening, Ask Suicide-Screening Questions, Malay language, psychiatric patients, Malaysia, concurrent validity, sensitivity, screening accuracy, Brief Suicide Safety Assessment, cross-cultural translation, mental health, BMC Psychiatry