Childhood Suicide Risk in the Emergency Department.

Importance: Suicide rates have increased in recent years to the third leading cause of death among youths. Children presenting to the emergency department (ED) for suicide thoughts and behaviors (STB) are at high risk for recurrent mental health (MH) concerns. Objective: To quantify rates of STB among children presenting to EDs across the US and to identify risk factors for return ED visits for STB. Design, Setting, and Participants: This cohort study examined electronic health records of children who presented to the ED from January 2010 to December 2020 using the State Emergency Department Database within the Healthcare Cost and Utilization Project. All ED visits were screened among children aged 8 to 12 years in 12 states with data linking patients across visits. International Classification of Disease (ICD) codes separated non-STB MH and STB-related visits. Data were analyzed from August 2024 to January 2025. Main Outcomes and Measures: Analyses examined characteristics of visits for MH vs STB and patients returned for subsequent ED visit(s) for STB. Analyses compared visits for MH vs. STB and examined factors related to subsequent ED return visit(s) for STB. This included sociodemographic, clinical, and temporal factors derived from electronic health records. Results: A total of 10 131 432 ED visits were screened, and 627 517 visits (6%) among 374 118 unique patients implicated ICD codes for non-STB MH causes (534 654 visits [5%]; mean [SD] age, 10.25 [1.41] years; 189 701 female [35%]) or STB (92 863 visits [1%]; mean [SD] age, 10.87 [1.27] years; 50 679 female [55%]). MH and STB visits increased from 36 623 ED visits (5%) in 2010 to 22 443 ED visits (10%) in 2020. Compared with non-STB MH visits, patients with STB were more likely to have private insurance and reside in areas with higher income and less deprivation (via linkage to social deprivation index). There was an age-by-sex interaction (z = 48.22; P < .001); a greater percentage of STB patients were female at older ages vs younger ages. Suicide behaviors mostly implicated injury by ingestion (7121 [43%]) or sharp or blunt object (6518 [39%]). Additionally, 68 897 patients had multiple ED visits (18%), 6537 with multiple STB visits (10%); 117 377 of 187 864 return ED visits were within 3 months (62%). STB was strongly associated with ED return for STB (aOR, 9.71 [99% CI, 9.66-9.76]; z = 127.93). Return STB visits within 1-year were more common for females and patients with more MH comorbidity, longer initial visits, and without private insurance. Conclusions and Relevance: Suicide risk is common but remains understudied among children. Early suicide risk was associated with recurrent STB, particularly in the months following ED discharge. Understanding risk and protective factors among children can enhance ED screening, intervention, and follow-up care.