Abstract
Objectives
To describe the association between recent bullying victimization and risk of suicide among pediatric emergency department (ED) patients.
Methods
Patients presenting to one of three different urban pediatric EDs with either medical/surgical or psychiatric chief complaints completed structured interviews as part of a study to develop a suicide risk screening instrument, the Ask Suicide-Screening Questions (ASQ). Seventeen candidate items and the criterion reference Suicidal Ideation Questionnaire (SIQ) were administered to patients ages 10 to 21 years. Bullying victimization was assessed by a single candidate item (“In the past few weeks, have you been bullied or picked on so much that you felt like you couldn't stand it anymore?”).
Results
A total of 524 patients completed the interview (34.4% psychiatric chief complaints; 56.9% female; 50.4% white, non-Hispanic; mean age 15.2±2.6 years). Sixty patients (11.5%) reported recent bullying victimization, and of these, 33 (55.0%) screened positive for suicide risk on the ASQ or the previously validated SIQ. After controlling for demographic and clinical variables, including a history of depression and drug use, the odds of screening positive for suicide risk were significantly greater in patients who reported recent bullying victimization (adjusted odds ratio=3.19, 95% CI=1.66-6.11). After stratification by chief complaint, this association persisted for medical/surgical patients but not for psychiatric patients.
Conclusions
Recent bullying victimization was associated with increased odds of screening positive for elevated suicide risk among pediatric emergency department patients presenting with medical/surgical complaints. Understanding this important correlate of suicide risk in pediatric emergency department patients may help inform ED-based suicide prevention interventions.
Keywords: bullying, suicide risk, youth, emergency department
INTRODUCTION
Youth who are victims of bullying, termed bullying victimization, may be at increased risk of suicide.1 A recent review on the association of bullying and suicide reported increased odds of suicide risk among victims of bullying in both cross-sectional and longitudinal studies.2 These studies examined diverse populations, including self-identified lesbian, gay, or bisexual children and adolescents;3-4 juvenile offenders in custody;5 and middle school and high school students.6-9 Studies examining bullying victimization and suicide risk among youth seen in pediatric emergency departments (EDs) are lacking.
The pediatric ED has become a de facto setting to address concerns along the entire public health continuum.10-15 In fact, for approximately 1.5 million children and adolescents, the ED is their only source of contact with the healthcare system.10 In response to this demand on pediatric EDs to provide holistic care and/or linkage with mental health treatment, in 2009, the American Academy of Pediatrics (AAP) issued a policy statement identifying pediatricians, including those working within the ED setting, as critical stakeholders in the prevention of bullying victimization, noting the significant symptom morbidity (e.g., stomachaches, headaches) and school absenteeism linked with bullying.16-19 Moreover, there is a high prevalence of bullying victimization among patients presenting to the ED.18 While many of these presentations signal a psychiatric referral, bully victims often present with nonspecific symptomotaology.18 Thus, bullying victimization may be a relevant component of physical or mental illness.
EDs have also recently been targeted as a primary venue for identifying youth at risk for suicide. The AAP and Joint Commission (JC) both recommend screening all ED patients for suicide risk.20-21 Understanding psychosocial correlates of suicide risk, such as bullying victimization, may help guide ED-based interventions and referrals. However, there have been no studies examining bullying victimization and risk of suicide in youth who present to pediatric EDs. The aim of this report is to describe the association between recent bullying victimization and risk of suicide within a large multisite sample of pediatric ED patients who presented with either medical/surgical or psychiatric chief complaints.
MATERIALS AND METHODS
Sample and Setting
In a previously reported, prospective, cross-sectional, multisite study of a convenience sample of youth age 10-21 years, inclusive, interviews were conducted that developed the Ask Suicide-Screening Questions (ASQ), a suicide risk screening instrument.12 Data were collected between September 10, 2008 and January 5, 2011 at three pediatric EDs associated with urban teaching hospitals: Children's National Medical Center in Washington, DC; Nationwide Children's Hospital in Columbus, OH; and Boston Children's Hospital in Boston, MA. Exclusion criteria were: 1) developmental disability, cognitive impairment, or communication disorder that interfered with the patient's ability to comprehend and communicate about the study; 2) triage level 1 (for medical/surgical patients), suggesting medical instability; 3) parent/guardian unavailable (for patients age 17 years and younger); and 4) patients and/or parents/guardians who were non-English speaking. Written informed consent was obtained from all patients age 18 years and older; for patients younger than 18 years, written assent was obtained from the patient, and written informed consent was obtained from the parent/guardian. The study was approved by National Institutes of Health Combined Neuroscience Institutional Review Board and the IRBs at the participating institutions. Further methodologies of this multisite study have been described.12
Measures
Elevated risk of suicide was defined as a positive response to one or more of the four questions on the ASQ or as an age-specific positive score (i.e., above a cut-off score, described below) on the Suicidal Ideation Questionnaire (SIQ).
ASQ
As previously reported,12 for the larger study that developed the ASQ, a list of 17 candidate items was assembled and asked of all participants. The 17 candidate items were identified from several sources, including published literature, interviews with youth suicide experts and senior clinicians, and the Risk of Suicide Questionnaire.22 One of the 17 items screened for recent bullying victimization: “In the past few weeks, have you been bullied or picked on so much that you felt like you couldn’t stand it anymore?” If a participant responded “yes,” indicating the presence of recent bullying victimization, participants were further queried to describe if the bullying was physical, emotional, or both. This single item was not selected as part of the final 4-question model comprising the ASQ due to low agreement with the SIQ, as measured by the chance-corrected kappa statistic.12 The final 4-item ASQ had a sensitivity of 96.9% (95% CI, 91.3-99.4), specificity of 87.6% (95% CI, 84.0-90.5), and negative predictive values of 99.7% (95% CI, 98.2-99.9) for medical/surgical patients and 96.9% (95% CI, 89.3-99.6) for psychiatric patients (see Table 1). An answer of “yes” to any of the four ASQ items indicates a positive screen for clinically significant suicide risk that warranted further evaluation.
Table 1.
Ask Suicide-Screening Questions (ASQ)12
| 1) In the past few weeks, have you wished you were dead? |
| 2) In the past few weeks, have you felt that you or your family would be better off if you were dead? |
| 3) In the past week, have you been having thoughts about killing yourself? |
| 4) Have you ever tried to kill yourself? |
| If yes, how?__________________________________ |
| When?______________________________________ |
Note. A response of “yes” to any one of the four questions indicates a positive screen for elevated suicide risk.
SIQ
This measure served as the criterion reference for the development of the ASQ. The SIQ is a self-report measure of the severity of suicidal ideation in youth.23 In the ASQ study, adolescents age 15 years or older completed the full 30-item version of the SIQ; youth age 14 years or younger completed the 15-item SIQ-Junior (SIQ-JR). In both versions, participants were asked to rate the frequency with which a thought occurred in the past month on a 7-point scale (e.g., “I thought that killing myself would solve my problems;” 0 = “I never had this thought”; 6 = “Almost every day”). Consistent with prior use of the SIQ,23 a cutoff score of 41 or greater (SIQ) or 31 or greater (SIQ-JR) was used to establish the severity level of suicidal ideation that warranted further psychiatric evaluation. Additionally, several items were considered critical items, meaning answers in the affirmative indicate clinically significant suicidal ideation, irrespective of total scores. On the SIQ, there are 8 critical items; the cut-off score indicating clinically significant suicidal ideation is 3. On the SIQ-JR, there are 6 critical items; the cut-off score is 2. Both versions of the SIQ have strong psychometric properties, including high reliability (SIQ r = 0.97; SIQ-JR r = 0.94) and validity.
All participants were administered a structured interview inquiring about demographic and clinical variables. Patients were coded as positive for a history of diagnosed depression if they answered in the affirmative to the following question: “Has a mental health professional or your pediatrician ever told you that you were depressed?” Patients were coded as positive for a history of drug use if they answered “yes” to either of the following questions: “Have you ever used marijuana?” or “Do you ever use any other hard drugs?”
Statistical Analysis
All analyses were conducted using Stata version 11.0.24 Descriptive demographic variables were tabulated with means and standard deviations or proportions. The chi-squared and Student's t-test were employed to analyze bivariable differences between patients who did and did not report recent bullying victimization. Multiple logistic regression was used to estimate the adjusted odds (adjOR) and 95% confidence interval (CI) of suicide risk associated with recent bullying victimization after controlling for age, gender, race/ethnicity, insurance type (as a proxy for socioeconomic status), history of diagnosed depression, and self-reported drug use. These demographic and clinical variables were included in the statistical models as covariates because they are robust risk factors for both bullying18 and suicide25 in youth.
RESULTS
Participants
Participant characteristics, including age, gender, race/ethnicity, insurance status, and psychiatric history are presented in Table 2. Overall, 524 patients (56.9% female; 50.4% white, 29.6% black; mean age 15.2y±2.6y) who presented to the ED with either medical/surgical (344/524; 65.6%) or psychiatric (180/524; 34.4%) chief complaints were included in the analyses.
Table 2.
Participant characteristics stratified by reported bullying victimization and by chief complaint
| Entire Cohort | Medical/Surgical Complaints | Psychiatric Complaints | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| All (n=524) |
Bullying (n=60) |
No bullying (n=464) |
Group Differences |
Medical / Surgical Complaints (n=344) |
Bullying (n=22) |
No bullying (n=322) |
Group Differences |
Psychiatric Complaints (n=180) |
Bullying (n=38) |
No bullying (n=142) |
Group Differences |
|
| Age | 15.2 (2.6) | 13.6 (2.6) | 15.4 (2.5) | t(522) = 5.20, p<0.001 | 15.7 (2.6) | 14.4 (3.4) | 15.7 (2.6) | t(342) = 2.38, p<0.05 | 14.4 (2.3) | 13.3 (2.0) | 14.8 (2.3) | t(178) = 3.82, p<0.001 |
| Gender | ||||||||||||
| Female | 298 (56.9) | 34 (56.7) | 264 (56.9) | χ2 = 0.00, p = 0.973 | 193 (56.1) | 10 (45.5) | 183 (56.8) | χ2 = 1.08, p = 0.298 | 105 (58.3) | 24 (63.2) | 81 (57.0) | χ2 = 0.46, p = 0.497 |
| Race/Ethnicity | ||||||||||||
| White | 264 (50.4) | 30 (50.0) | 234 (50.4) | χ2 = 5.08, p = 0.534 | 162 (47.1) | 9 (40.9) | 153 (47.5) | χ2 = 4.71, p = 0.581 | 102 (56.7) | 21 (55.3) | 81 (57.0) | χ2 = 5.88, p = 0.318 |
| Black | 155 (29.6) | 21 (35.0) | 134 (28.9) | 103 (29.9) | 9 (40.9) | 94 (29.2) | 52 (28.9) | 12 (31.6) | 40 (28.2) | |||
| Hispanic | 47 (9.0) | 4 (6.7) | 43 (9.3) | 36 (10.5) | 1 (4.5) | 35 (10.9) | 11 (6.1) | 3 (7.9) | 8 (5.6) | |||
| Asian | 12 (2.3) | 0 (0) | 12 (2.6) | 9 (2.6) | 0 (0) | 9 (2.8) | 3 (1.7) | 0 (0) | 3 (2.1) | |||
| Other/unknown | 46 (8.8) | 5 (8.3) | 41 (8.8) | 34 (9.9) | 3 (13.6) | 31 (9.6) | 12 (6.7) | 2 (5.3) | 10 (7.0) | |||
| Insurance | ||||||||||||
| Private | 279 (53.2) | 29 (48.3) | 250 (53.9) | χ2 = 2.31, p = 0.510 | 179 (52.0) | 10 (45.5) | 169 (52.5) | χ2 = 1.27, p = 0.737 | 100 (55.6) | 19 (50.0) | 81 (57.0) | χ2 = 4.05, p = 0.256 |
| Public | 196 (37.4) | 27 (45.0) | 169 (36.4) | 132 (38.4) | 10 (45.5) | 122 (37.9) | 64 (35.6) | 17 (44.7) | 47 (33.1) | |||
| Public & private | 16 (3.1) | 2 (3.3) | 14 (3.0) | 9 (2.6) | 0 (0) | 9 (2.8) | 7 (3.9) | 2 (5.3) | 5 (3.5) | |||
| None | 33 (6.3) | 2 (3.3) | 31 (6.7) | 24 (7.0) | 2 (9.0) | 22 (6.8) | 9 (5.0) | 0 (0) | 9 (6.3) | |||
| Psychiatric history | ||||||||||||
| Depression | 139 (26.5) | 22 (36.7) | 117 (25.2) | χ2 = 3.57, p = 0.059 | 52 (15.1) | 3 (13.6) | 49 (15.2) | χ2 = 0.04, p = 0.841 | 87 (48.3) | 19 (50.0) | 68 (47.9) | χ2 = 0.05, p = 0.817 |
| Substance use | 106 (20.2) | 10 (16.7) | 96 (20.7) | χ2 = 0.53, p = 0.465 | 54 (15.7) | 6 (27.3) | 48 (14.9) | χ2 = 2.38, p = 0.123 | 52 (28.9) | 4 (10.5) | 48 (33.8) | χ2 = 7.91, p = 0.005 |
| Site | ||||||||||||
| CNMC | 156 (29.8) | 20 (33.3) | 136 (29.3) | χ2 = 2.73, p = 0.256 | 106 (30.8) | 6 (27.3) | 100 (31.1) | χ2 = 4.33, p = 0.114 | 50 (27.8) | 14 (36.8) | 36 (25.4) | χ2 = 2.88, p = 0.237 |
| BCH | 199 (38.0) | 17 (28.3) | 182 (39.2) | 117 (34.0) | 4 (18.2) | 113 (35.1) | 82 (45.6) | 13 (34.2) | 69 (48.6) | |||
| NCH | 169 (32.2) | 23 (38.3) | 146 (31.5) | 121 (35.2) | 12 (54.6) | 109 (33.9) | 48 (26.7) | 11 (29.0) | 37 (26.1) | |||
Note: Values are n(%); age is calculated as a mean, so parentheses for the age row contain standard deviations (SDs). CNMC = Children's National Medical Center; BCH = Boston Children's Hospital; NCH = Nationwide Children's Hospital.
Self-Reported Recent Bullying Victimization
Of the entire cohort of 524 participants, 60 (11.5%) patients reported a recent history of being bullied (Table 2). With regard to the type of bullying experienced (i.e., emotional vs. physical), 54 (91.5%) reported being emotionally bullied, 18 (30.5%) reported being physically bullied, and 13 (22.0%) reported experiencing both. Patients presenting with medical/surgical complaints were significantly less likely to report bullying than patients with psychiatric chief complaints [22/344 vs. 38/180, (OR 0.26, 95% CI=0.15-0.45)].
Participants who reported recent bullying victimization were significantly younger than those who did not report recent bullying victimization [13.6±2.6 years vs. 15.4±2.5 years, p<.001]. There were no significant differences in gender, race/ethnicity, insurance status, depression, and drug use among those who did and did not report recent bullying victimization.
Suicide Risk
A positive screen on the SIQ (ages 15-21 years), the SIQ-JR (ages 10-14 years), or the ASQ (all participants, ages 10-21 years) was considered “at risk” for suicide. Of the 524 total participants, including both medical/surgical and psychiatric patients, 151 (28.8%) patients screened positive for elevated risk of suicide on the SIQ or ASQ. Patients presenting with medical/surgical complaints were significantly less likely to screen positive than patients with psychiatric chief complaints [34/344 vs. 117/180, (OR 0.06, 95% CI=0.04-0.09)].
Relationship between Self-Reported Recent Bullying Victimization and Suicide Risk
Of the 60 participants who reported recent bullying victimization, 33 (55.0%) screened positive for suicide risk while 118/464 participants (25.4%) who did not report recent bullying victimization screened positive for suicide risk [OR 3.58 (95% CI = 2.07-6.21)]. In a multivariate model that controlled for variables that are independently associated with increased risk of suicide in youth, recent bullying victimization remained significantly associated with elevated risk of suicide [adjOR 3.19 (95% CI = 1.66-6.11)] (Table 3). After stratification by chief complaint (i.e., medical surgical vs. psychiatric), recent bullying victimization remained significantly associated with elevated risk of suicide among medical patients [adjOR 4.62 (95% CI = 1.25-17.05)]; however, the association was not significant among psychiatric patients [adjOR 1.88 (95% CI = 0.78-4.54)].
Table 3.
Multivariate model of bullying victimization as a predictor of screening positive for elevated suicide risk for entire cohort and stratified by chief complaint.
| Entire Cohort (N=524) | ||||
|---|---|---|---|---|
| Entire Cohort (n=524) | Bullying (n=60) | No bullying (n=464) | Adjusted OR (95% CIs) | |
| Suicide Risk SIQ+ or ASQ+ | 151 (28.8) | 33 (55.0) | 118 (25.4) | 3.19 (1.66-6.11)* |
| Medical/Surgical Complaints (n=344) | ||||
|---|---|---|---|---|
| Medical/Surgical Complaints (n=344) | Bullying (n=22) | No bullying (n=322) | Adjusted OR (95% CIs) | |
| Suicide Risk SIQ+ or ASQ+ | 34 (9.9) | 5 (22.7) | 29 (9.0) | 4.62 (1.25-17.05)* |
| Psychiatric Complaints (n=180) | ||||
|---|---|---|---|---|
| Psychiatric Complaints (n=180) | Bullying (n=38) | No bullying (n=142) | Adjusted OR (95% CIs) | |
| Suicide Risk SIQ+ or ASQ+ | 117 (65.0) | 28 (73.7) | 89 (62.7) | 1.88 (0.78-4.54)* |
Note. Values are n(%) unless otherwise noted.
Age, gender (male), race (white), insurance (public), depression, and substance use were entered into the logistic regression models as covariates.
DISCUSSION
In a large and diverse cohort of pediatric ED patients, recent bullying victimization was significantly associated with elevated risk of suicide. This association persisted after controlling for demographic and clinical risk factors commonly associated with elevated suicide risk in youth.
Our finding that 11.5% of the youth in our cohort reported recent bullying victimization is similar to findings from other studies.18 Consistent with research demonstrating that youth with a mental illness are at increased risk of both suicide and bullying victimization,13,25 significantly more patients presenting with psychiatric complaints than with medical/surgical complaints reported bullying victimization and screened positive for suicide risk. However, when stratified by chief complaint, recent bullying victimization was not significantly associated with suicide risk among psychiatric patients. This surprising finding may be a result of the modest sample size of psychiatric patients (n=180), or perhaps for psychiatric patients, comorbid psychopathology (e.g., clinical depression) may account for greater variance in screening positive for suicide risk. This finding is not consistent with previous bullying research in other settings.1,2 It is possible that because the bullying item used in this study assesses recent bullying victimization, this may have missed capturing a chronic course of bullying in psychiatric patients, thus affecting our results; this is noted below in the limitations section. Interestingly, among medical/surgical patients, even after controlling for self-reported history of depression and drug use, a report of recent bullying victimization remained significantly associated with elevated odds of screening positive for suicide risk.
Of the 17 candidate items tested for inclusion in the final ASQ model, the item assessing recent bullying victimization was not included. The final 4 items selected assessed current and passive thoughts of suicide and past suicidal behavior (Table 1).12 This suggests that asking pediatric ED patients questions using validated screening instruments that directly probe for suicidal thoughts and behaviors may be the best strategy to identify youth at risk for suicide.26,27 Although the bullying item did not prove specific enough to be a valid screening question for suicide risk in a general ED population, this current analysis indicates that, among pediatric ED patients, recent bullying victimization may be an important risk factor for suicide.
The following limitations must be considered. First, the cross-sectional design restricts the ability to form causal inferences; although patients who report recent bullying victimization are more likely to screen positive for suicide risk, it does not necessarily mean that bullying causes suicidal thoughts or behaviors. While other longitudinal and population based studies examining the association between bullying and suicide risk exist, there are no studies examining this association among ED patients. Second, because these data were part of a larger instrument development study utilizing 17 candidate items, bullying victimization was measured using a single dichotomous item; this was an exploratory sub-analysis of a larger study, and we believe this item measured a participant's perception of feeling bullied, but this was not a validated item.
Future studies should assess bullying victimization using a more comprehensive, psychometrically sound, and nuanced approach.28 Third, bullying was not defined for participants in this study, and perceptions of what constitutes bullying victimization may vary. Fourth, all information was gathered via self-report by a convenience sample of patients; collateral information from parents, clinicians, or educators can be important for assessing bullying and was not obtained for this dataset. Fifth, although previous research suggests that youth who are both a victim and perpetrator of bullying may be at greatest risk for suicide,1,2 we did not assess if victims were also perpetrators of bullying. Important covariates of bullying and suicide risk, including alcohol use and anxiety, were unable to be assessed. Importantly, we also did not assess for lifetime bullying victimization, and instead assessed for recent bullying victimization; we believe this is more relevant for an ED setting, in which more acute and recent stressors are triaged. Given the limited scope of the bullying item used in this study, it is likely that the prevalence rates of bullying victimization in the ED reported in this study are underestimates. Finally, the participants were drawn from academic, urban pediatric EDs, and our findings may not generalize to other ED patient populations.
Conclusions
In a multisite sample of pediatric ED patients, children and adolescents presenting with medical/surgical complaints who reported bullying victimization were significantly more likely to screen positive for suicide risk. Once a child screens positive for suicide risk, clinicians should inquire about bullying victimization. Although not all youth who are bullied are at increased risk of suicide, knowledge of bullying victimization may help inform ED-based interventions and mental health referrals. Results suggest that pediatric ED patients who report recent bullying victimization should be screened for suicide risk.
Acknowledgments
Funding Source: All phases of this study were supported by the Intramural Research Program of the National Institute of Mental Health. Dr. Bridge was supported by institutional research funds from The Research Institute at Nationwide Children's Hospital, CDC grant R01 CE-002129, and NIMH grants K01 MH-69948 and R01 MH-93552. Dr. Wharff was supported by institutional research funds from the Program for Patient Safety and Quality at Boston Children's Hospital. The funding organizations did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Abbreviations
- AAP
American Academy of Pediatrics
- adjOR
adjusted odds ratio
- ASQ
Ask Suicide-Screening Questions
- CI
confidence interval
- ED
emergency department
- JC
Joint Commission
- SIQ
Suicidal Ideation Questionnaire
- SIQ-JR
Suicidal Ideation Questionnaire-Junior
Footnotes
Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.
Conflict of Interest: The authors have no conflicts of interest to disclose. The views expressed in the article do not necessarily reflect the views of the National Institute of Mental Health, the National Institutes of Health, the Centers for Disease Control and Prevention, the U.S. Department of Health and Human Services, or the U.S. government.
Previous Presentations: Partial results from this study were presented as a platform presentation at the annual meeting of the Pediatric Academic Societies in Washington, DC on May 6th, 2013 and a portion was presented at the 2013 International Academy of Suicide Research in Montreal, Canada.
REFERENCES
- 1.Kim YS, Leventhal B. Bullying and suicide: A review. Int J Adolesc Med Health. 2008;20(2):133–154. doi: 10.1515/ijamh.2008.20.2.133. [DOI] [PubMed] [Google Scholar]
- 2.Klomek AB, Sourander A, Gould M. The Association of Suicide and Bullying in Childhood to Young Adulthood: A Review of Cross-Sectional and Longitudinal Research Findings. Can J Psychiatry. 2010;55(5):282–288. doi: 10.1177/070674371005500503. [DOI] [PubMed] [Google Scholar]
- 3.Hatzenbuehler ML. The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth. Pediatrics. 2011;127:896–903. doi: 10.1542/peds.2010-3020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Friedman MS, Koeske GF, Silvestre AJ, et al. The impact of gender-role nonconforming behavior, bullying, and social support on suicidality among gay male youth. J Adolesc Health. 2006;38:621–623. doi: 10.1016/j.jadohealth.2005.04.014. [DOI] [PubMed] [Google Scholar]
- 5.Kiriakidis SP. Bullying and Suicide Attempts Among Adolescents Kept in Custody. Crisis. 2008;29(4):216–218. doi: 10.1027/0227-5910.29.4.216. [DOI] [PubMed] [Google Scholar]
- 6.Klomek AB, Marrocco F, Kleinman M, et al. Bullying, Depression, and Suicidality in Adolescents. J Am Acad Child Adolesc Psychiatry. 2007;46(1):40–49. doi: 10.1097/01.chi.0000242237.84925.18. [DOI] [PubMed] [Google Scholar]
- 7.Klomek AB, Kleinman M, Altschuler E, et al. High School Bullying as a Risk for Later Depression and Suicidality. Suicide Life Threat Behav. 2011;41(5):501–516. doi: 10.1111/j.1943-278X.2011.00046.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Schneider SK, O'Donnell L, Stueve A, et al. Cyberbullying, School Bullying, and Psychological Distress: A Regional Census of High School Students. Am J Public Health. 2012;102(1):171–177. doi: 10.2105/AJPH.2011.300308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.van der Wal M, de Wit CAM, Hirasing RA. Psychosocial Health Among Young Victims and Offenders of Direct and Indirect Bullying. Pediatrics. 2003;111:1312–1317. doi: 10.1542/peds.111.6.1312. [DOI] [PubMed] [Google Scholar]
- 10.Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatr Adolesc Med. 2000;154(4):361–365. doi: 10.1001/archpedi.154.4.361. [DOI] [PubMed] [Google Scholar]
- 11.Larkin GL, Beautrais AL. Emergency Departments Are Underutilized Sites for Suicide Prevention. Crisis. 2010;31(1):1–6. doi: 10.1027/0227-5910/a000001. [DOI] [PubMed] [Google Scholar]
- 12.Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): A Brief Instrument for the Pediatric Emergency Department. Arch Pediatr Adolesc Med. 2012;166(12):1170–1176. doi: 10.1001/archpediatrics.2012.1276. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Srabstein J, Joshi P, Due P, et al. Prevention of public health risks linked to bullying: A need for a whole community approach. Int J Adolesc Med Health. 2008;20(2):185–199. doi: 10.1515/ijamh.2008.20.2.185. [DOI] [PubMed] [Google Scholar]
- 14.Anderson P, Petrino R, Halpern P, et al. The globalization of emergency medicine and its importance for public health. Bull World Health Organ. 2006;84:835–839. doi: 10.2471/blt.05.028548. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Bernstein SL, Haukoos JS. Public Health, Prevention, and Emergency Medicine: A Critical Juxtaposition. Acad Emerg Med. 2008;15(2):190–193. doi: 10.1111/j.1553-2712.2008.00055.x. [DOI] [PubMed] [Google Scholar]
- 16.Committee on Injury, Violence, and Poison Prevention Role of the Pediatrician in Youth Violence Prevention. Pediatrics. 2009;124:393–402. doi: 10.1542/peds.2009-0943. [DOI] [PubMed] [Google Scholar]
- 17.Fekkes M, Pijpers FIM, Fredriks M, et al. Do Bullied Children Get Ill, or Do Ill Children Get Bullied? A Prospective Cohort Study on the Relationship Between Bullying and Health-Related Symptoms. Pediatrics. 2006;117:1568–1574. doi: 10.1542/peds.2005-0187. [DOI] [PubMed] [Google Scholar]
- 18.Waseem M, Ryan M, Foster CB, et al. Assessment and Management of Bullied Children in the Emergency Department. Pediatr Emer Care. 2013;29(3):389–398. doi: 10.1097/PEC.0b013e31828575d7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Srabstein JC, McCarter RJ, Shao C, et al. Morbidities associated with bullying behaviors in adolescents: School based study of American adolescents. Int J Adolesc Med Health. 2006;18(4):587–596. doi: 10.1515/ijamh.2006.18.4.587. [DOI] [PubMed] [Google Scholar]
- 20.Committee on Pediatric Emergency Medicine Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System. Pediatrics. 2011;127:e1356–e1366. doi: 10.1542/peds.2011-0522. [DOI] [PubMed] [Google Scholar]
- 21.The Joint Commission A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department. Sentinel Event Alert. 2010;(46):1–4. [PubMed] [Google Scholar]
- 22.Horowitz LM, Wang PS, Koocher GP, et al. Detecting Suicide Risk in a Pediatric Emergency Department: Development of a Brief Screening Tool. Pediatrics. 2001;107:1133–1137. doi: 10.1542/peds.107.5.1133. [DOI] [PubMed] [Google Scholar]
- 23.Reynolds W. Suicidal Ideation Questionnaire. Psychological Assessment Resources; Odessa, Florida: 1988. [Google Scholar]
- 24.StataCorp . Stata Statistical Software: Release 11. StataCorp LP; College Station, TX: 2009. [Google Scholar]
- 25.Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006;47:372–394. doi: 10.1111/j.1469-7610.2006.01615.x. [DOI] [PubMed] [Google Scholar]
- 26.Stanley IH, Snyder D, Westen S, et al. Self-Reported Recent Life Stressors and Risk of Suicide in Pediatric Emergency Department Patients. Clin Pediatr Emerg Med. 2013;14:35–40. doi: 10.1016/j.cpem.2013.01.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Ballard ED, Horowitz LM, Jobes DA, et al. Association of Positive Responses to Suicide Screening Questions With Hospital Admission and Repeated Emergency Department Visits in Children and Adolescents. Pediatr Emer Care. 2013;29(10):1070–1074. doi: 10.1097/PEC.0b013e3182a5cba6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Hamburger ME, Basile KC, Vivolo AM. Measuring Bullying Victimization, Perpetration, and Bystander Experiences: A Compendium of Assessment Tools. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; Atlanta, GA: 2011. [Google Scholar]