Which validated suicide risk assessment instrument is recommended for children and adolescents, including those under 12 years and those aged 12‑18 years?

Validated Suicide Risk Assessment Instruments for Children and Adolescents

Direct clinical questioning remains the primary recommended approach for suicide risk assessment in children and adolescents, rather than reliance on any single validated scale, because existing suicide screening instruments lack sufficient predictive value and must always be followed by comprehensive clinical evaluation. 1

Primary Assessment Approach

Direct Screening Questions (All Ages)

The most evidence-based approach involves asking specific, direct questions during clinical interviews:

• "Have you ever thought about killing yourself or wished you were dead?" – This general question should be placed in the middle or toward the end of depression symptom questions 1
• "Have you ever done anything on purpose to hurt or kill yourself?" – Ask this regardless of the answer to the first question 1
• "If you were to kill yourself, how would you do it?" – Assess for specific plans if either previous question is positive 1
• Inquire about firearm access in the home – This is a critical safety assessment component 1

Why Direct Questioning Supersedes Scales

Screening scales are oversensitive and underspecific, lacking predictive value for actual suicide completion; they serve only as adjuncts to trigger clinical evaluation, never as standalone decision-making tools. 1

• Instruments studied in high-risk adolescent populations show sensitivity of only 52–87% and specificity of 60–85%, and these results are only generalizable to high-risk populations, not general pediatric settings 1
• Self-administered scales can be useful because adolescents may disclose suicidality on paper that they deny in person, but any positive screen must be followed by direct clinical interview 1
• A child or adolescent who screens positive on any suicide scale must always be assessed clinically – scales cannot substitute for clinical judgment 1

Depression Screening Tools with Suicide Items

PHQ-9 (Ages 12–18 Years)

The PHQ-9 is the most widely recommended validated instrument for adolescents aged 12–18 years, primarily as a depression screener that includes a suicide item (item 9). 1, 2

• The PHQ-9 has been validated in adolescent primary care populations with sensitivity of 89.5% and specificity of 77.5% at a cutoff score of 11 for detecting major depressive disorder 2, 3
• Item 9 specifically assesses thoughts of self-harm: "Thoughts that you would be better off dead or of hurting yourself in some way" – any positive response requires immediate clinical follow-up 2, 3
• Universal depression screening with the PHQ-9 is recommended starting at age 12 years and continuing through age 18 years 2, 3

Critical limitation: The PHQ-2 (brief two-item version) omits the suicide item entirely and can miss patients with suicidal ideation who don't endorse core depressive symptoms, so it should not be used when suicide screening is the priority 3

PHQ-9 for Younger Children (Under 12 Years)

No validated depression or suicide screening instruments are recommended for children under age 11 years. 3

• The USPSTF evidence reviews for depression screening did not include children younger than age 11 years 3
• Most treatment trials demonstrating efficacy were restricted to adolescents aged 12–14 years or older 3
• For children under 12, rely exclusively on direct clinical questioning adapted to developmental level, using play observation and interviews with parents 1

Columbia-Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is a semistructured interview-based tool that has been validated in adolescent populations for research and clinical use, but it requires trained administration and does not replace clinical judgment. 4, 5

Psychometric Properties

• The C-SSRS has demonstrated good internal consistency and inter-rater reliability in adolescent samples 4
• A three-factor structure fits the data: (1) severity of suicidal ideation, (2) intensity of suicidal ideation, and (3) suicidal behavior 4
• The tool successfully discriminates adolescents with recent suicide attempts from other clinical groups 4
• In Spanish-speaking adolescents, cutoff scores of ≥6 for suicidal ideation and ≥4 for suicidal behavior showed adequate detection ability 5

Clinical Application

• The C-SSRS is a semistructured interview, not a brief self-report questionnaire that can be administered without training 4, 6
• Brief self-report versions adapted from the C-SSRS have shown promise for screening in non-clinical settings like schools, but require validation in specific populations 7
• The C-SSRS provides more detailed assessment of suicidal ideation and behavior than brief screeners, but still requires follow-up clinical evaluation for positive screens 5

Age-Specific Recommendations

Children Under 12 Years

Use direct clinical questioning exclusively, adapted to the child's developmental level, with heavy reliance on parent/caregiver interviews and behavioral observation. 1

• Gathering information from multiple sources is essential because children's cognitive development affects their ability to report time, cause, and emotional states accurately 1
• Use play observation and behavior assessment in addition to interviews 1
• Children are more likely to report suicidal ideation than their parents, so always interview the child directly in addition to parents 1
• Disruptive disorders increase suicide risk in children 12 years and younger 1

Adolescents 12–18 Years

Begin with the PHQ-9 as a universal depression screen (which includes suicide item 9), then follow any concerning responses with direct clinical questioning using the structured approach outlined above. 1, 2

• Self-administered scales are particularly useful in adolescents because they may disclose information on paper that they deny in person 1
• Always follow positive screens with face-to-face clinical assessment 1
• Assess for mood disorders, substance abuse, anxiety disorders, prior attempts, access to lethal means, and family/peer conflicts 1, 2

Critical Assessment Components Beyond Scales

Evaluate Suicidal Intent and Lethality

Assess the method used or planned, degree of planning, efforts to avoid detection, and perceived versus actual lethality – these factors predict future attempts better than any scale score. 2

• Methods other than medication ingestion or superficial cuts signal higher risk of repeat attempts 2
• Deliberate actions to avoid detection (concealment, secrecy) indicate greater suicidal intent 2
• Children and adolescents often overestimate the lethality of chosen methods, so significant intent may not result in a lethal act 2
• Prior attempts are the strongest predictor of future attempts 2

Assess Underlying Psychiatric Disorders

Major depressive disorder, bipolar disorder, anxiety disorders, and substance use disorders are the primary psychiatric risk factors requiring immediate identification and treatment. 1, 2

• Depression screening instruments shown to be valid in adolescents include the PHQ-9 and PHQ-2 1
• Mood disorders, particularly early-onset major depressive disorder, independently increase suicide attempt risk in both sexes 1
• Panic attacks increase risk in females; aggressiveness increases risk in males 1

Environmental and Psychosocial Risk Factors

• Physical and sexual abuse account for approximately 15–20% attributable risk among female attempters 2
• LGBTQ youth have significantly higher rates of suicidal ideation and attempts 1, 2
• Runaway or homeless adolescents exhibit high prevalence of suicidality, frequently linked to prior abuse 2
• Access to firearms must be assessed and removal arranged for any at-risk youth 1, 2

Common Pitfalls to Avoid

• Never dismiss suicidal thoughts or comments as "gestures" or attention-seeking – this minimizes real risk 1, 2
• Never rely solely on a scale score to determine risk – always conduct clinical interview 1
• Never assume absence of current suicidal ideation means low risk – patients who previously attempted remain at elevated risk if precipitating factors haven't changed 2
• Never use "suicide contracts" – they have not demonstrated efficacy in preventing attempts 2
• Never screen without having a clear protocol for managing positive results – screening alone without intervention pathways does not improve outcomes 3

Summary Algorithm

For children under 12: Use direct clinical questioning adapted to developmental level + parent interview + behavioral observation (no validated scales exist) 1, 3

For adolescents 12–18: Administer PHQ-9 as universal depression screen → If item 9 positive OR total score ≥10, conduct structured clinical interview with direct suicide questions → Assess intent, plan, access to means, psychiatric disorders, and psychosocial risk factors → Determine disposition (outpatient follow-up vs. emergency mental health evaluation vs. hospitalization) based on clinical assessment, not scale scores 1, 2, 3