What is the ASQ Suicide Screening Tool?

by | Sep 1, 2025 | Suicide Prevention | 2 comments

asq questions horowitz

This information was extracted from the transcripts of Dr. Lisa Horowitz’s webinar about the ASQ Suicide Screening Tool.

mental health speaker video

See the ASQ Suicide Screening Tool Webinar on YouTube with Dr. Lisa Horowitz

Other Important Resources:

Why should we do universal screening of suicide risk?

The ASQ Suicide Screening Tool is a standardized, research-based method to give a healthcare provider a validated way to ask awkward questions and start a really challenging but important conversation with a patient. It is a validated tool for youth 10 years of age and up, and is also validated for use on adults. It can be used for children as young as 8 when indicated, and universal health screening offers more health equity.

Age Recommendations for Screening

  • Youth ages 10+: universal screening
  • Youth ages 8-10: screen when clinically indicated
  • Youth under age 8: screening not indicated. Assess for suicidal thoughts/behaviors if warning signs are present
  • Validated for adults, too

All of us can help prevent suicide. For those 10-24 years old in 2023, almost 20% of the deaths that occurred were from something that is potentially preventable–suicide. For youth overall, it has dipped slightly starting in 2021, and we hope to keep that trend going downward.

Is it safe to ask about suicide?

There are at least 4 studies now showing that it’s not only safe to ask kids about suicide risk, but it is a way to save their lives.

The 4 Studies

If someone wasn’t thinking about suicide before, and you ask them, you are not putting the idea into their head. What you’re doing is recognizing a warning sign, and you’re asking and starting a very awkward but critical conversation.

NIMH partnered with Parkland, a large hospital in Dallas, Texas, to conduct a study using the ASQ screening tool. After conducting 90,000 pediatric screenings, the team found that 97% of patients screened negative, indicating that only 3% of patients screened positive.

How do you do screening without overburdening very busy healthcare providers?

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97% of patients screened negative, indicating that only 3% of patients screened positive. Study: Universal Pediatric Suicide Risk Screening in a Health Care System: 90,000 Patient Encounters

If you’re in an

  • Emergency department, it might be a higher screen positive rate, like 6 or 7% (~94% would be negative screens)
  • Primary care might be 3 or 4% (97% would be negative screens)
  • Older kids might be 10% (90% would be negative screens)

The rates of screen positives vary, and we know the majority of patients will screen negative (no suicidal intent). That matters in a healthcare system because this means the screening is not overburdening a busy healthcare system.

It takes 20 seconds to do the screening, and when it’s done, you just destigmatized suicide and normalized the conversation, because you’re saying, “This is important.”

The most common positive is a non-acute positive

You can either be non-acute or acute positive.

And from this Parkland Memorial Hospital study of 90,000 patients, 99.5% of positive screens were non-acute. So, the majority of patients who screen positive, who are telling you they’re thinking about suicide, might not be an emergency.

That means only 0.5% will be acute positive screens requiring immediate attention.

The ASQ has been tested in all medical settings, inpatient, outpatient, and specialty clinics. It has undergone a multi-site study in adults, and research is ongoing.

ihs logo

The NIMH now has a partnership with the Indian Health Service (IHS), which has mandated that all 130 IHS facilities around the USA use the ASQ as their suicide risk screening tool. Training in all regions wrapped up in late 2025, so this can take place in IHS medical facilities, which started September 1, 2025.

The ask is also translated into over 23 languages and tested in multiple countries.

What is the recommended ASQ suicide screening process?

  1. ASQ Screen (~20 seconds)
  2. Brief Suicide Safety Assessment (BSSA administered by a clinician). Further triage of the screen. (10 minutes)
  3. Identify the next steps that the person needs
Universal Suicide Risk Screening Clinical Pathway
Brahmbhatt, Kurtz, Afzal…Pao, Horowitz, et al. (2018). Psychosomatics

See this part of the webinar: Universal Suicide Risk Screening Three-Tiered Clinical Pathway

Universal Suicide Risk Screening Clinical Pathway and Protocol

asq questions
ASQ suicide screening questions

If the patient says yes to any of those four questions above, you ask the fifth acuity question, “Are you having thoughts of killing yourself right now?”

Designate who will be screening. Anyone who is trained can screen for suicide risk: Nurses, Technicians, Medical Assistants, Clinicians, and Doctors.

Protocol for screening in a pediatric practice:

  1. Tell the parent/guardian to step outside (don’t ask, tell them politely)
  2. Administer the ASQ verbatim (ask the questions as they are written)
  3. “Score” the ASQ in real time
  4. Report screening findings to a designated clinician

Age Recommendations for Screening

  • Youth ages 10+: universal screening
  • Youth ages 8-10: screen when clinically indicated
  • Youth under age 8: screening not indicated. Assess for suicidal thoughts/behaviors if warning signs are present

Details for pediatric practice:

  1. You tell the parent or guardian to step outside so you can screen in private.
  2. If they won’t leave, you screen in front of them.
  3. The ASQ has to be administered exactly as it’s written, because it is an evidence-based tool.
  4. It’s scored in real time, and the findings have to be reported to the medical team before the visit starts, or as soon as possible.

It’s recommended that you universally screen everyone who is cognitively able to answer questions, medically stable enough to answer questions, and 10 years old and over.

For kids 8-10, screen when it’s clinically indicated. So clinicians need to be trained on the warning signs.

If a parent comes in and says, “Every time I discipline my 7-year-old, they grab their throats and say they want to die,” that’s a warning sign. You don’t need a screening tool. You just heard that they’re at risk.

In that case, you go straight for the assessment, BSSA (Brief Suicide Safety Assessment). (found on the toolkit page)

We can’t treat every person, young or old, who has a thought about suicide like an emergency

Maybe the screener is the first person who’s ever asked them about suicide, and on this day, they were brave enough to speak about it.

If we then send them to the ER, and they’re put in a paper gown, their phone’s taken away, and they’re given a very costly one-on-one sitter, and they’re there for hours and hours. This patient might be sorry that they ever spoke about it, and may never speak about it again.

To the patient, this feels like a punishment.

The clinical pathway is a guide to help avoid these unnecessary interventions. Most will not need to go to the emergency room.

If someone does screen acute positive

While rare, sometimes a patient will score an acute positive, meaning they are at immediate risk for suicide, and it becomes an emergency. In these cases, the patient needs to be sent to the ER — but staff must be trained to handle the situation with compassion, clearly explaining the process and setting expectations.

Patients need to understand why their belongings are being removed and why a security guard may be outside their door. They should be reassured that safety is the top priority and that these measures are not a punishment, but a way to keep them safe.

When there is an acute positive — a “yes” to questions 1–4 and a “yes” to question 5 — the high-risk protocol must be followed:

  • The patient cannot be left alone and must be under constant observation.
  • Any potentially harmful items should be removed from the room.
  • They need an urgent, full mental health evaluation.
  • They cannot leave the facility until they are cleared for safety, because we are all mandated reporters when someone is at risk of dying by suicide.

Again, this situation is unusual — it happens, but it’s not the most common presentation of a positive screen.

Most often, the result is a non-acute positive. This means the patient said yes to at least one question, but no to question 5: “Are you thinking about killing yourself right now?”

A non-acute positive signals that something important has been detected, but it’s not an emergency

In these cases, the patient needs a brief suicide safety assessment with a clinician.

Follow-up often includes a check-in call the next day to ensure support and continued care.

They can be left alone if there are no other safety concerns — this approach has been reviewed and approved by the Joint Commission, an independent, non-profit organization that accredits and certifies thousands of healthcare organizations in the United States and internationally to improve the quality and safety of healthcare for the public.

What if the patient or parent declines the assessment (BSSA)?

They are not restrained or treated like a criminal. Instead, the clinician documents the refusal and determines the safest discharge plan.

So, we’re trying to make this a more patient-centered and compassionate process.

It comes down to those three steps, the Universal Suicide Risk Screening Three-Tiered Clinical Pathway.

Universal Suicide Risk Screening Three Tiered Clinical Pathway
Universal Suicide Risk Screening Three-Tiered Clinical Pathway

While the steps are the same, there are hundreds of ways to implement them, and the nuance matters.

How you adapt the process to your specific setting is critical. This is done through a quality improvement process — a repetitive, iterative approach where you continuously refine and improve efficiency.

The brief suicide safety assessment (BSSA) is ideally done by a social worker

However, most places don’t have the luxury of a social worker. So another clinician, a nurse practitioner or a physician assistant works, too.

In the Indian Health Service, we train pharmacists to do the BSSA. You could train residents, trainees, and fellows to do a brief suicide safety assessment.

There are two tools people use, either the Columbia Suicide Severity Rating Scale (CSSRS) or the ASQ Brief Suicide Safety Assessment (BSSA), which we made so people could do further triage of the ASQ.

Whatever tool you use, it helps the clinician decide the next steps for this patient. If this patient screened positive, are they an imminent risk? If so, they may need an emergency visit.

Are they low risk? Then nothing more has to happen at this time.

The harder category is the yellow

You identified something, it’s not an emergency, but they need further evaluation as soon as possible.

“These conversations are so hard to have, and I am trained to assess someone for suicide, and every single time I go for a suicide risk assessment, and I send a patient home rather than to the emergency room, I walk away with, white knuckles. And I just pray that I did the right thing. That I made the right decision.
Because it’s so hard to know, and you never really know. And then, if it’s someone in my personal life and I’m worried about them, this is not an easy conversation to have, even for someone who knows the words. It’s always awkward, but it’s always important.”

Lisa M. Horowitz, PhD, MPH

Why do universal suicide risk screening?

A patient’s depression becomes a disorder when it starts to impact functioning. That can be when the person stops getting out of bed in the morning, when a kid stops wanting to go to school, when they’re not getting their work done, when all of a sudden somebody who was taking showers stops taking them, and they look different.

The majority of kids who die by suicide do not have a diagnosable mental illness, but mental illness is still a risk factor.

One study of preteens showed that a third of them who had died by suicide had told an adult directly that they were thinking about it.

In February of 2022, the AAP declared suicide risk screening as something pediatricians should do alongside depression screening. And they picked the age of 12 years and above, and they picked 12 to align with the age they were using for depression screening. NIMH researchers are working toward convincing them that we should go down to 10 years of age.

Can we save lives by screening for suicide risk in medical settings?

Yes, it’s a great place to save lives.

Why? Because the majority of people who die by suicide, and this is not just adults, but young people too, have visited a healthcare provider, not just months, but sometimes weeks, sometimes within a week before taking their own life.

The problem is, they don’t come in and say to the doctor or the nurse, “You know, I’m thinking of killing myself.”

They’re coming in with medical complaints.

So if someone doesn’t ask them directly, “Are you thinking of killing yourself?” they most likely won’t talk about it. So the majority of suicide attempters go unrecognized, because the majority of medical settings don’t screen for suicide risk.

One JAMA study showed that 60% of young people who died by suicide had no documented mental health diagnosis. This is the best evidence for why we should do universal suicide risk screening, why every child over the age of 10 in pediatric practices should be screened for suicide risk.

Parents and their reaction to suicide screening their children

When testing the ASQ, we asked parents, “Do you think kids should be screened for suicide risk in medical settings?”

And the majority of parents did think their kids should be asked— 74%.

Seventy-four percent (185/248) of parents reported that nurses should screen kids for suicide risk in the doctor’s office, with one parent stating, “Kids feel comfortable at the doctor’s office.” A portion of parents, 16% (41/248), reported they were “not sure,” and 8% (20/248) did not think nurses should screen for suicide risk (1% (2/248) did not respond).

Parents not in favor of screening reported concerns over mixing physical and mental health, “The child is [at the doctor’s office] to fix a physical ailment.” Eighty percent (199/248) of parents reported being “somewhat” or “very” comfortable with their child being screened and 6% (16/248) of parents reported being “somewhat” or “very” uncomfortable with their child being screened. The remaining 13% (33/248) of parents were “neutral”. When asked specifically if they had concerns about screening, most parents (218/248; 88%) reported that they had none.

Horowitz LM, Bridge JA, Tipton MV, Abernathy T, Mournet AM, Snyder DJ, Lanzillo EC, Powell D, Schoenbaum M, Brahmbhatt K, Pao M. Implementing Suicide Risk Screening in a Pediatric Primary Care Setting: From Research to Practice. Acad Pediatr. 2022 Mar;22(2):217-226. doi: 10.1016/j.acap.2021.10.012. PMID: 35248306; PMCID: PMC8908796.

Common themes of parents being in favor were that they felt like maybe their kids would be more comfortable sharing with a medical professional. And they felt suicide prevention was important, and they thought that it destigmatized the conversation if pediatricians brought this up with all the other medical things they’re asking about.  

Fifteen percent of parents were against screening, and they said things like,

  • “This is going to make my child feel uncomfortable.”
  • “You’re going to put the idea into their head where they weren’t thinking about it before, and now they’re going to be thinking about it.” (which has been shown not to be the case)

13 Reasons Why Series on Netflix

There is a difference between asking very compassionately someone that you care about if they are thinking about suicide, and putting it on TV in a dramatization. There is a study where the researchers looked at what happened when 13 Reasons Why, which was a Netflix series, was released.

And it turned out that there was an excess of hundreds of suicides that occurred after the release of 13 Reasons Why. That’s because it was a dramatization. The person who died was in every episode getting revenge, and it glamorized suicide.

There were no trusted adults that did anything when people were reaching out for help, so there could be, suicide contagion when vulnerable kids watch media about suicide risk, so this is very different than talking about it… this is a vulnerable kid watching something that’s dramatized, and then getting, you know, thinking, oh, okay, that’s an option. So, two different things.

The release of 13 Reasons Why was associated with a significant increase in monthly suicide rates among US youth aged 10 to 17 years. Caution regarding the exposure of children and adolescents to the series is warranted.

Source: Association Between the Release of Netflix’s 13 Reasons Why and Suicide Rates in the United States: An Interrupted Time Series Analysis, Jeffrey A. Bridge, Joel B. Greenhouse, Donna Ruch, Jack Stevens, John Ackerman, Arielle H. Sheftall, Lisa M. Horowitz, Kelly J. Kelleher, John V. Campo

Photo of the Researchers in Baltimore, the day the study was released. While AnneMoss was not part of the research team, she was part of the presentation team at the Pediatric Academic Societies presentation, the day it was released. Campo, Bridge, and Horowitz are pictured on the right.

13 reasons why phd investigators

The difference between screening and assessment

People mix these terms and use them interchangeably, and they are absolutely not interchangeable.

Screening is a very brief way to identify someone who needs further assessment. It’s quick.

That is very different than the assessment, which is a more comprehensive evaluation. It confirms risk, and guides next steps.

Can depression screening be used to effectively screen for suicide risk? (e.g., PHQ-9)

mental health speaker video

See the section on this topic in the webinar

See the YouTube Short on the PHQ-9 and why it’s not a good tool for screening for suicide risk.

Study 2021: Limitations of Screening for Depression as a Proxy for Suicide Risk in Adult Medical Inpatients

One question I got when the AAP said screen for suicide risk alongside depression was that a lot of pediatricians were already screening for depression. Can’t we just use that as our suicide risk screen?

At least 13 research studies have shown that the PHQ-9, while being a good depression screen, is not sufficient to identify people at risk for suicide.

When we were testing the ask on the inpatient medical surgical unit, we had 600 kids, 81 screened positive for suicide risk, 103 screened positive on the PHQ.

While the PHQ is a good depression screening tool, there is no evidence that using the PHQ-2 and PHQ-9 is a good way to screen for suicide risk.

Below is a YouTube short that talks about why PHQ is not a good tool for detecting suicide risk and can potentially miss well over half of pediatric patients who might be thinking of suicide.

PHQ-2 to PHQ-9 and then the ASQ. Too many hoops!

The question is, why would you make the patient jump through all those hoops when you can start with the ASQ? Below is the process some clinical settings use. But there is a better way.

phq and suicide risk

Pediatricians told us they wanted one tool, one piece of paper. The answer was that we combined the ASQ with the PHQ-A (Patient Health Questionnaire for Adolescents), resulting in a single piece of paper.

adobe pdf download

Combined depression screening (PHQ) and the ASQ Suicide Screening Tool on ONE sheet of paper.

For Adolescents: PHQ-A + the ASQ, one sheet of paper

For Adults: PHQ-9 + the ASQ, one sheet of paper

There are 3 brief interventions that everyone can do that make a difference for suicide prevention

Do screening, and they’ll say to me, you know what, we can’t really do this, because we don’t have any access to mental health care, which unfortunately is happening throughout our country.

So if you don’t have access and you can’t get a full mental health evaluation, there are still 3 things you can do for that patient.

  1. You can do safety planning. Everyone can be trained to do a safety plan.
  2. You could do lethal means safety counseling. How do you make sure that the house is safe so the person at risk doesn’t have access to something to end their life?
  3. And you can provide 988, which is a lifeline for many people. So there are things you can do.

It is so important to reduce access to lethal means because when someone’s in a suicidal state, they’re not thinking clearly. Their brain isn’t working properly. So if something is around, like a firearm, or a pesticide, or pills, they might do something to harm themselves, because they’re not using their good judgment. It’s important to lock up firearms with a thumbprint safe for example. You are putting time between thought and action.

It’s really important to keep the house safe, and then provide resources like 988 and the Crisis Text Line, 741-741. You can call or text together with the person in distress when possible so they are part of the process and don’t feel like something is being said behind their back. (CALM lethal means training is free.)

You can say or do:

  • “I’ve seen you’ve been through hard things; I know how resilient you are.”
  • “We’re gonna get through this together, right?”
  • “I have your back as you’ve had mine.”
  • “It’s a profound privilege to support you and to have earned your trust.”
  • You can connect them with a mental health professional as soon as possible.

Webinar Story: How one pediatric nurse, on a feeling, screened a teen, which saved his life. (the link will take you directly to the story)

I recommend that people who use the Columbia start with the ASQ as the primary screener, then use the Columbia for the assessment. However, the ASQ and the BSSA were specifically designed to work together and meet the requirements set forth by the Joint Commission. The ASQ is also very quick — it was developed through research, rigorously tested, and validated.

Regarding the different languages, the tool is not a one-to-one translation in every single language because of cultural responsiveness. So, if you don’t have that language, you can use an interpreter, but it’s recommended you pull up the version of the ASQ in the language the patient is speaking as it is written with these cultural sensitivities in mind. There is also a telehealth version as well as a school version. (See the ASQ Toolkit page for those versions.)

Can the ASQ be used in Schools?

There is a school version of the ASQ that was made for school systems that wanted it. In that case, we replaced the word “patient” with the word “student.” A school nurse’s office is a good place to screen.

When you screen in a school, you need the entire school approach. You can’t just start screening. You have to train people on suicide prevention. You have to train the teachers, the administration, the coaches, and the kids. How do you recognize suicide risk among your peers?

(There will be a follow-up webinar featuring school systems that are using this tool.)

Sources:

Studies that have shown that asking about suicide doesn’t plant the idea in someone’s head:

Suicide Assessment Tools

2 Comments

  1. Spider Kalusha
    Spider Kalusha on September 4, 2025 at 12:56 am

    I love the ASQ tool, very helpful. How I wish you people should extremely extend such programs to developing countries like my country Zambia and Many African countries. Lives are being lost nearly every day, different ways. With the idea of reaching out to hospitals, clinics, community etc, it is a welcome move. Using health practitioners, so good. People in our countries lack much of such information, to help on sensitization, due to a small number of people willing to take part in such programs. You only see people working up once a life is Lost, which is very unfortunate. Other Wise some of us are scared, we do not know why such cases are becoming so tampered all over the world. Let’s share ideas, systems on how to go about it. Children are remain homeless, grandmas, mothers are losing bread winners with this same scourge, it is not right. Anne Moss Rogers, and the team extend your vast ideas to the world, in order to save lives. We are waiting for for you to go international with those tools, thanks.

    Reply
    • AnneMoss Rogers
      AnneMoss Rogers on September 4, 2025 at 1:38 pm

      Thank you Spider. I love that you care so much about what is happening in your country, Zambia.

      Reply

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