Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth

JAMA Psychiatry. 2021 May 1;78(5):540-549. doi: 10.1001/jamapsychiatry.2020.4576.


Importance: The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services.

Objective: To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs).

Design, setting, and participants: Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts.

Exposures: Presentation at an ED.

Main outcome and measure: A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report.

Results: The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [63.0%]; mean [SD] age, 15.1 [1.61] years) with 3-month follow-ups (72.9% retention [2075 adolescents]). The study 2 validation sample included 2754 adolescents (1711 female adolescents [62.1%]; mean [SD] age, 15.0 [1.65] years), with 3-month follow-ups (69.5% retention [2754 adolescents]). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 [95% CI, 0.85-0.91]) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 [95% CI, 0.85-0.89]). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1.

Conclusions and relevance: In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.
  • Validation Study

MeSH terms

  • Adolescent
  • Child
  • Diagnosis, Computer-Assisted / instrumentation
  • Diagnosis, Computer-Assisted / standards*
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Neuropsychological Tests / standards*
  • Prognosis
  • Risk Assessment / standards*
  • Sensitivity and Specificity
  • Suicide, Attempted*
  • User-Computer Interface*