Notes on Assessing Suicide Risk in Children: Developmentally Appropriate Interviewing
Assessing Suicide Risk in Children — Developmentally Appropriate Interviewing (Notes)
Purpose of the article: Review risk factors for childhood suicide, evaluate current assessment methods, and outline developmentally appropriate interviewing guidelines for risk assessment with children.
Context: Childhood suicide risk is under-recognized due to myths, misclassification, and clinician discomfort; professionals must be prepared to assess and intervene despite challenges. The field draws on models across biological, psychological, cognitive, and environmental domains, with emphasis on integrated, multidimensional approaches.
Core idea: Identifying risk factors across multiple domains and using developmentally sensitive interviewing strategies improves accuracy of risk assessment and safety planning for children aged roughly $5$ to $14$ years and beyond.
Risk Factors for Suicide
Theoretical and conceptual models guide interpretation of risk factors; authors advocate for integrated theoretical approaches rather than isolated theories. Key references: Berman, Jobes, & Silverman (2006); Stillion & McDowell (1996); Westefeld et al. (2000).
Multidimensional Suicide Trajectory Model (Stillion & McDowell, 1996): links biological, psychological, cognitive, and environmental risk factors to stressors and triggering events that may lead to suicidal ideation/behavior across developmental stages.
General premise: While not all with risk factors become suicidal, most who are suicidal present with multiple risk factors.
Clinical utility: Examination of risk factors helps identify children needing deeper assessment (Wise & Spengler, 1997) and informs risk level evaluation for those with ideation (Weller et al., 2001).
Biological Risk Factors
Higher impulsivity in children increases risk for impulsive suicide attempts/gestures (e.g., running into traffic, jumping from a height).
Sex and age differences emerge early: very young children show similar attempts/completions by sex, but by age $10$ sex differences in completed suicide rates appear; by adolescence, boys complete more often while girls attempt more (AAS, 2006; Wise & Spengler, 1997).
Age is a risk factor even within the $5 o 14$ year-old range due to maturation and rising impulsivity.
Psychological Risk Factors
Feelings of inferiority and the "expendable child syndrome" (Stillion & McDowell, 1996).
Disturbances in psychological functioning and presence of one or more diagnosable mental health disorders (Brent & Kolko, 1990; Gould et al., 2003; Weller et al., 2001; Wise & Spengler, 1997).
Common symptoms: depression (most frequent); also anxiety, aggression, impulsivity.
Internalizing problems and poor coping skills are common; hopelessness about the future often observed (Brent & Kolko; Juhnke, 1996).
Cognitive Risk Factors
Immature views of death and concrete thinking styles; how a child understands life/death affects risk.
Rational thinking loss as a risk factor (Juhnke, 1996).
Possible perceptual phenomena: auditory/visual hallucinations (Pfeffer, 2003); commands to self-harm imply serious ideation and reduced capacity to distinguish thoughts from hallucinations.
Links to impulsivity and substance use: recent drug/alcohol use can worsen rational thinking and increase risk (Juhnke, 1996).
Environmental Risk Factors
Family/household context: early loss, parental conflict, chaotic/inflexible family structures, abuse, neglect, and parental suicidal behaviors elevate risk.
Family distress and dysfunction can hinder caregiving and safety (Wise & Spengler, 1997; Brent & Kolko, 1990; Gould et al., 2003).
Social isolation, loneliness, poor social support, and poor social skills increase risk (Stefanowski-Harding, 1990; Weller et al., 2001; Brent & Kolko, 1990).
School problems: learning disabilities and academic failure associated with increased risk (Gould et al., 2003; Stillion & McDowell, 1996; Wise & Spengler, 1997).
Precipitating Events
Recent psychosocial stressors or changes can trigger risk; examples include family crises, health problems, or other events perceived as uncontrollable by the child.
Environmental exposure to suicide or contagion can heighten risk (Brent & Kolko, 1990; Gould et al.).
Triggering events for high-risk children may appear trivial to adults (e.g., denied privilege or ordinary punishment).
Prior suicidal ideation and prior attempts are among the strongest predictors of future suicidality; presence of a concrete suicide plan markedly elevates risk (Gould et al.; Juhnke, 1996; Weller et al.; Wise & Spengler).
Preparing to Assess Children for Suicide
Counselor preparation is essential: address personal thoughts, feelings, and fears about crisis work with children (Shea, 1999).
Preparation helps mitigate denial of seriousness, misinformation, and rushed interviewing (Stefanowski-Harding, 1990; Wise & Spengler, 1997).
Consider developmental level in advance; adapt language and questions to fit the child’s abilities (Hendren, 1990).
Before interviewing, review available information (age, development, risk factors) to tailor communication and anticipate needs.
Develop a memory aid or checklist (e.g., adapted SAD-PERSONS, Juhnke, 1996) to stay on track during high-stress crisis work.
Guidelines for Developmentally Appropriate Interviewing
Suicide risk assessment often occurs within crisis assessment/intervention; balance engaging the child with building an action plan in the child’s best interest.
Framework: Plan and conduct crisis assessment; establish rapport; identify problems; address feelings; generate alternatives; develop action plan; plan follow-up (Roberts, 2000; adapted for children) — seven-step crisis intervention model.
These steps frame the following recommendations and can be adapted for child-specific suicide risk assessment.
Plan and Conduct a Crisis Assessment
Initial moments: greet child and caregiver; engage in a bit of small talk to convey interest and care; state the specific reason for the interview; structure the interview to be comforting rather than punitive.
Sample openings:
"Tell me why you are here today." or
"Tell me why your teacher thought you should come here."
Provide a short explanation if the child says, "I don’t know": e.g., "Your mom is worried you might be very sad, and I am here to help."
Communicate at the outset that the child is not in trouble, it is safe to tell the truth, and there are no right or wrong answers; tailor clarifications by age.
Check for understanding; allow breaks; invite questions about the interview.
Confidentiality and guardianship: AMHCA/ACA Codes of Ethics emphasize balancing confidentiality with guardians’ involvement; discuss expectations and limits of confidentiality early (AMHCA 2000; ACA 2005).
Decide who will be present for which portions of the interview; caregiver presence can aid support but may lead to the child being less forthcoming; sometimes structure the interview to include both joint and individual segments.
Plan structure at the outset and adapt as needed (Aldridge & Wood, 1998; Wilson & Powell, 2001).
Assessment Methods
Multi-method, multi-source, and multi-tiered approaches are recommended (Goldston, 2003; Wise & Spengler, 1997).
Unstructured clinical interviews are common for children; general suicide-risk screening question suggested: "do things ever get so bad you think about hurting yourself?"; follow-up for suicidal ideation, self-harm, and related symptoms.
Unstructured parent interviews yield collateral information about functioning, family environment, stressors, and communication/nurturing patterns (Hendren, 1990; Weller et al., 2001; Wise & Spengler).
Play, drawings, and storytelling can reveal suicidal themes; interpret cautiously and in context of broader data (Hendren, 1990; Wise & Spengler, 1997).
Written instruments often more comfortable for youth; adolescents may disclose ideation more readily on written formats; some childhood-focused tools exist but may be lengthy or not fully validated for crisis settings (Goldston, 2003; Klimes-Dougan, 1998).
Notable instruments discussed:
CSPS (Child Suicide Potential Scale) — comprehensive questions about risk factors and death understanding; rated on a 5-point scale from nonsuicidal to serious attempt; practical but lengthy for crisis settings. Relevant formula:
ChIPS (Children's Interview for Psychiatric Syndromes) — developmentally appropriate DSM-IV disorder questions; parent-ChIPS and child-ChIPS used in multi-task interviews (Weller et al., 1999; 2001).
Practical note: Structured interviews can aid systematic assessment of disorders and risk factors but may be less feasible in urgent crisis contexts; clinicians may use portions of structured protocols to inform questions about depression and affective symptoms.
Establish Rapport and Rapidly Establish Relationship
Building rapport is particularly challenging when interviewer is unknown and content is threatening; children may struggle with language, concepts (e.g., depression, suicide), or grammar.
Nonverbal cues: caregivers’ and clinicians’ facial expressions and nodding influence child disclosures; clinicians should be mindful of how these cues are perceived.
Questioning style: use mainly open-ended questions with closed-ended follow-ups; avoid overwhelming the child; tailor to developmental level (Aldridge & Wood, 1998; Bourg et al., 1999).
For younger or less verbal children, closed-ended questions can be more effective; pace questions slowly; avoid why-questions, avoid multiple-choice formats; avoid repeating yes-no questions; use short sentences with simple words; check understanding frequently.
When including caregivers, balance child protection with child autonomy; consider asking child who should be present and whether to interview separately.
Assessment Methods (continued)
Identify major problems: allow the child to provide a free narrative of events leading up to the appointment (free narrative promotes rich, context-specific information).
Non-directive prompts (e.g., "tell me about what happened today"); consider drawings or puppets to elicit stories in concrete terms.
Begin broadly and move to specifics as the story unfolds; use closed-ended questions to fill gaps.
If vague suicidal ideation is observed, follow up directly but sensitively; avoid forcing elaboration about thoughts; use non-directive prompts like "tell me more" or "what does that mean?".
When discussing thoughts of death, focus on concrete behavior language (e.g., events, descriptions) to reduce shame and improve accuracy; if a suicide attempt or plan is disclosed, explore it with care.
Gentle assumptions are recommended when discussing possible self-harm (e.g., "How long have you felt like hurting yourself?"). This approach can normalize the discussion while avoiding direct pressure.
Normalize carefully; reflect the precipitating event and acknowledge the child’s experience, while asking about thoughts of death or self-harm.
Pfeffer (2003) developmentally appropriate probes include:
Did you ever think that you wanted to hurt yourself?
Did you ever try to hurt yourself?
Tell me about what you did.
When did you do this?
Did you ever think about killing yourself?
Did you ever plan to kill yourself?
Did you ever try to kill yourself?
When did you try to do this?
If verbal communication is difficult, drawing or other expression (e.g., pictures of what they think or feel) can help reveal ideation.
Always assess for: existence of a suicide plan, intent, means, and perceived outcomes of taking action; explore understanding of death and potential motivators (e.g., wanting to reunite with lost loved ones, misunderstandings about death).
Pfeffer (2003) cautions clinicians to take all accounts seriously; children can plan/act on suicide even if they do not fully understand death consequences (see Pfeffer, 1986 for the Child Suicide Potential Scale).
Identify Major Problems (Follow-up approach)
Use free narrative and then targeted questions to clarify precipitating events and current suicidal ideation.
Use gentle, concrete prompts to elicit details about what happened, who was involved, and what the child was feeling.
If a plan or intent is indicated, escalate risk assessment and safety planning; document details clearly for caregivers and service providers.
Include caregivers in the process as appropriate to safety planning while ensuring child’s safety and rights remain central.
Deal with Feelings and Emotions
Reflecting feelings and sustaining techniques are essential across ages; provide calm presence, grounding strategies, and breaks as needed.
Use relaxation techniques (breathing, waiting, slow pace) and physical props (squish ball, play-doh) to reduce tension during the interview.
For less verbal children, ask them to draw or use a "feeling face" poster to identify emotions; tailor prompts to the child’s communication style and comfort level.
Generate and Explore Alternatives
Transition from assessment to intervention; caregivers’ involvement is crucial for safety planning, given that children cannot provide full consent for actions.
Co-construct an action plan with the child and family; discuss concerns with caregivers and assess feasibility and safety at home.
Consider meeting with caregivers separately to secure support before presenting plans to the child.
Assess caregiver capacity to maintain safety; caregiver reports may underestimate risk; consider incongruities between child and caregiver reports.
Fristad & Shaver (2001) suggest caregiver education/consultation as a key risk-reduction strategy in many cases; involve social services or involuntary commitment only when necessary and carefully considered.
Develop and Formulate Action and Follow-Up Plans
Activate resources, include 24-hour crisis access information, and plan for potential inpatient hospitalization if needed.
Schedule follow-up appointments and coordinate safety-providing resources (support networks, school accommodations, etc.).
Review the entire plan with all involved to ensure acceptability and feasibility; confirm with the child and caregivers that the plan is understood and agreed upon.
Conclusion and Ethical Considerations
Suicidal behavior is not rare; counselors are often in a key position to identify, assess, and coordinate care for children with suicidal ideation/behavior.
Ethical responsibilities include developmentally appropriate assessment and crisis intervention readiness; this work can be emotionally charged and challenging.
Build competence through education on risk factors, self-reflection on personal discomforts, and creating an action plan for ongoing learning and practice.
Emphasize consultation, supervision, and peer support; debrief after difficult assessments to maintain professional and personal well-being.
Practical takeaways: structured interviewing approaches, caregiver involvement strategies, use of developmentally appropriate probes, and a clear plan for safety and follow-up.
Key References to Explore (selected)
Aldridge, M., & Wood, J. (1998). Interviewing children: A guide for child care and forensic practitioners.
American Counseling Association. (2005). Code of ethics.
American Mental Health Counselors Association. (2000). Code of ethics.
Juhnke, G. A. (1996). The adapted-SAD PERSONS: A suicide assessment scale designed for use with children.
Pfeffer, C. R. (1986, 2003). Child Suicide Potential Scales; Assessing suicidal behavior in children and adolescents.
Weller, E. B., et al. (1999, 2001). ChIPS and related interviews; overview and assessment of the suicidal child.
Roberts, A. R. (2000). Crisis Intervention Handbook; Lethality assessment and crisis intervention (Roberts & Yeager, 2005).
Wise, A. J., & Spengler, P. M. (1997). Suicide in children younger than thirteen: Clinical judgment and assessment issues.
Stillion, J. M., & McDowell, E. E. (1996). Suicide across the life span: Premature exits.
Bedrock model and related guidelines cited throughout the article (e.g., Stillion & McDowell 1996; Gould et al. 2003).
Notes: Numerical ranges and scales included in this note are denoted in LaTeX where appropriate, e.g., 5-14 ext{CSPS score} \in \{1,2,3,4,5}$$ for the CSPS scoring spectrum. The content reflects concepts and guidance from Barrio (2007) and cited sources within that article.