Identify

IDENTIFY Defined

Identify individuals with suicide risk via comprehensive screening and assessment.

Universal screening is recommended as part of the Zero Suicide framework. Every individual entering the system is screened for suicide thoughts and behaviors, and at regular intervals. Following all positive screens, an assessment is conducted to determine the level of risk and develop a plan for appropriate interventions. Screening and assessment are important but distinct components of the Identify element.

Research indicates that children and youth with suicide ideation often do not have a known mental health concern and that screening for mental health alone does not reveal suicidality—we need to directly ask about suicide. Furthermore, one-third of all youth with suicidal ideation will make a plan, and up to 60% will make a suicide attempt1. Therefore, suicide-specific screening is essential to early intervention. The American Academy of Pediatrics recommends universal screening for youth ages 12 and up and clinically indicated screening for children between 8 and 11 years of age. Under the age of 8, screening is not indicated but clinicians should assess for suicide thoughts and behaviors when warning signs become evident2. It should be noted, however, that Black, indigenous, and people of color have been largely excluded in suicide research, so the following tools may not be culturally sound. When possible, efforts should be made to use culturally responsive language, translations, and clinical judgment.

Below are examples of evidence-based tools for suicide screening and suicide risk assessment. They can be used in many different organizations, including schools, youth-serving community-based organizations, and healthcare settings, such as the emergency department, inpatient, and outpatient medical care. 

Screening

  • The National Institute of Mental Health developed Ask Suicide-Screening Questions (ASQ), a 4-item tool to quickly screen individuals. The ASQ toolkit provides guidance, such as scripts, implementation workflows, and training.
  • The Patient Health Questionnaire-9 (PHQ-9A), often used in healthcare settings, measures depression severity and includes a single question that asks about the presence of suicide ideation. The PHQ-A includes has been modified for use with adolescents, and includes questions about past month suicide ideation and lifetime experience of suicide attempts.
  • The Columbia Suicide Severity Rating Scale (C-SSRS) 6-question screener has a version with language appropriate for young children (ages 6-11) and another for children ages 4-5 or those with cognitive impairment. Both offer modifications to wording but efforts should also be made to obtain information from collateral contacts to support accuracy of the screener. There is also a version for schools that includes a response protocol appropriate for the setting, and the C-SSRS is available in multiple languages.
  • A novel approach to screening is the Computerized Adaptive Screen for Suicidal Youth (CASSY). This technology-based tool, originally designed for universal use in emergency departments, may feel very comfortable for children and youth.  It can also be easily integrated into electronic health records.

Positive screens for suicide should be followed up immediately or as soon as possible with an evidence-based risk assessment.  The purpose of assessment is to determine next steps to plan for safety.

Brief Suicide Risk Assessment for Children and Youth

  • The Columbia Suicide Severity Rating Scale (C-SSRS) can be paired with the SAFE-T protocol, a five-step model for identifying risk factors and protective factors, suicidal intensity, risk stratification and interventions, and documentation. A mobile app for clinicians includes treatment resources, case scenarios, and conversation starters.
  • The Ask Suicide-Screening Questions (ASQ) is often followed by the Brief Suicide Safety Assessment (BSSA)—see ASQ toolkit for worksheet and guidance. It begins with validating and praising the individual for their response to the ASQ and prompts further disclosure about frequency, suicide plan, and past suicide behaviors, as well as an understanding of symptoms, social supports, and stressors. Finally, it includes a section for interviewing the youth and their parents or caregivers and safety planning. NOTE: additional resources for safety planning are found in the ENGAGE element.

Anticipated Barriers to Suicide Risk Screening and Assessment with Children and Youth

Common barriers to implementing suicide screening and risk assessment in settings that serve children and youth include staff lack of knowledge, discomfort with asking about suicide, concerns about lack of resources for follow-up, time constraints, and resistance from parents and caregivers1. Training and guidance are available for the evidence-based tools shared above and a range of professionals can be trained to screen and assess for suicide risk. Start by training individuals most comfortable with the topic to model effective practice and demonstrate that it can be integrated into existing workflow. In some instances, partnerships with other community providers can be helpful to support risk assessment if organizations do not have their own internal capacity.

Educate staff and families that asking children and youth about suicide does not increase their level of distress or suicidal thinking, or cause them to make an attempt. Instead, it gives them permission to talk about feelings that are likely very scary and difficult to understand, and opens the door for intervention and support.

When possible, screen youth in private, not in the presence of a parent or adult caregiver. For many reasons, a child may be reluctant to disclose in their presence. They may be concerned about making their parents feel sad or fear they will not be believed. In some instances, they may have already disclosed to an adult who was not able to offer a helpful response. Some youth may be concerned that sharing their suicidal thoughts might elicit questions they don’t feel comfortable answering, such as disclosing a traumatic experience, or sexual identity or orientation. Providing education to parents and caregivers in advance about youth suicide and the support and treatment that is available will be very helpful. Strategies to effectively support follow-up and access to care are provided in the ENGAGE and TRANSITION.

REMINDER: Visit the Zero Suicide Toolkit has additional information and resources.

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1 Milliman, C.M., Dwyer, P.A., Vessey, J.A. (2021). Pediatric Suicide Screening: A review of the evidence. Journal of Pediatric Nursing, 59,1-9.

2 American Academy of Pediatrics. Suicide: Blueprint for Youth Suicide Prevention. Available at https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/