Risk Assessment

Suicide risk assessment represents the cornerstone of effective therapeutic work with suicidal youth. While several suicide risk assessment instruments and scales are available, several of these scales generate a high number of “false positives” and should never be used alone or as a substitute for a thorough clinical assessment.

The best strategy is to develop a comprehensive, systematic and collaborative approach to assessing suicide risk that considers empirically validated risk factors and incorporates clinical knowledge and judgment. Examples of suicide risk assessment tools can be found under the “At-a-Glance Tools”.

The purpose of a comprehensive suicide risk assessment is to estimate the risk for suicidal behaviour based on a careful weighing of the clinically relevant risk and protective factors. In general, the greater the number of risk factors and the fewer the protective factors, the more elevated the risk for potential suicide and suicidal behaviour. Youth who have a number of risk factors (e.g. depression and substance abuse) and who have a previous history of suicidal behaviour and report having current and specific thoughts of suicide should be considered at high risk.

Most approaches to suicide risk assessment underscore the importance of systematically eliciting information across a number of key domains.⁴² ⁴³

Predisposing vulnerabilities (e.g. depression, substance use, previous history of suicidal behaviour).
Precipitating factors (e.g. conflict, break-up of relationship, health crisis).
Mental status, including: affective, cognitive, and behavioural states.
Current level of suicidal thinking and planning.
Protective factors (or contraindications), (e.g. coping skills, hopeful attitude towards the future, strong social support).

In addition, ongoing attention should be paid to the current level of suicidal intent (i.e. desire for death), reasons for suicide, and issues of lethality. A consideration of the young person’s level of engagement and willingness to follow through with treatment recommendations is also highly recommended.

One way to approach a comprehensive suicide risk assessment is to use a series of broad categories to guide your questioning and systematic inquiry. This, and other similar approaches, can also be adapted to provide the structure for your clinical record-keeping. For example:

Is the young person a member of an at-risk, vulnerable or socially marginalized group? (e.g. male, older adolescent, person living with a mental illness, GLBT)
What historical or predisposing factors may elevate suicide risk? (e.g. previous history of suicidal behaviour, family history of suicide, history of childhood maltreatment)
What are the presenting problems or current risk factors? (e.g. mental health status, impulsivity, aggression, stressful life events, relationship break-up, conflict with a family member, failure, disciplinary crisis,)
What is the level of current suicidal thinking and planning? (e.g. duration, specificity and intensity of ideation, level of planning, behavioural rehearsal)
What are some specific protective factors (e.g. coping and problem-solving skills, supportive family, relational connections and social support, plans for the future, willingness to ask for help)

When assessing risk for suicide in pre-pubertal children, consider the following:⁴⁴

children’s cognitive development
verbal skills
concepts of time
causality
understandings of death/suicide

Sample Questions to Ask Young Children About Suicide⁴⁵

Did you ever feel so upset that you wished you were not alive or wanted to die?
Did you ever do something that you knew was so dangerous that you could get hurt or killed?
Did you ever try to hurt yourself or kill yourself?
Did you tell anyone that you wanted to die or were thinking about killing yourself?
Did you do anything to get ready to kill yourself?
Did you think that what you did would kill you?
Do you think about killing yourself more than once or twice a day?
Have you tried to kill yourself since last summer/since school began?
What would happen if you died? What would that be like?
How do you remember feeling when you were thinking about trying to kill yourself?
How is the way you felt then different from the way you feel now?

Estimating Risk Levels

After a careful weighing of risk and protective factors, clinicians then need to estimate the current level of suicide risk. Clients are typically placed in one of the following risk categories or zones: none, low, moderate, high or imminent⁴⁶. The estimation of risk is both science and art and experienced clinicians recognize the importance of attending to the whole person, understanding suicide risk within a dynamic context, and being thorough and persistent in eliciting specific information. Five key cautions are worth noting:

Just because a young person denies suicide ideation, the suicide risk assessment process should not come to an end.
The absence of a history of suicide attempts does not mean that the individual is not at risk
The presence of only a few risk factors does not mean suicide can be ruled out
Clinicians cannot dismiss high suicide risk when client reports no ideation
The presence of protective factors does not serve to “cancel out” risk factors, especially when multiple imminent risk factors are present (frequent, intense ideation and strongly expressed intent to die)

The treatment plan developed by the clinician needs to correspond to the estimated level of risk. At a minimum, a treatment plan needs to address the following, all of which should be documented in the clinical record:⁴⁷

Site of treatment (in-patient or out-patient)
Members of therapeutic team (including adjunct therapies)
Overall approach to treatment (individual, group and/or family therapy)
Treatment goals
Primary treatment strategies
Safety and crisis response plans

Documentation

Maintaining a clear record that documents the risk assessment, estimation of risk, approach to safety planning, treatment goals, and clinical consultations is an important aspect of good clinical care. Documentation is important for the following reasons:⁴⁸

To convey relevant information to other professionals
To serve as a quality assurance checklist
To provide protection against malpractice
Good clinical documentation rests on good clinical care
Even if good clinical care has been provided, if the documentation is poor, the risk for litigation rises

Despite the additional time burden involved in adequately documenting a suicide risk assessment, out-patient clinicians are strongly encouraged to document their suicide risk assessment and treatment plans immediately following clinical evaluation of the client.⁴⁹ Overly simplistic “yes/no” tickable boxes (i.e. Is the client suicidal?) and subjective rating scales (from 1 to 5) are generally poor substitutes for a thorough risk assessment and a step-by-step account of subsequent clinical judgment and planning.

In out-patient settings, documentation of suicide risk should be undertaken as follows:⁵⁰

Initial interview
Emergence or re-emergence of suicide ideation, plans or attempts
Significant changes in the client’s condition

To summarize, key principles to keep in mind when assessing risk for youth suicide include:

To find out if suicide is a concern, we need to ask clients directly
It is not possible to predict individual suicides but we can estimate risk levels based on a thorough assessment
Approaches to assessing risk need to be developmentally appropriate and matched to the age and cognitive understanding of the client
The perspectives of parents, caregivers and other sources of collateral information should be actively sought out
Risk assessment requires an active consideration of the risk/protective factors ratio
In general, the greater the number of risk factors and the fewer the protective factors, the higher the potential risk
Risk status should be re-evaluated on a periodic basis
Treatment plans should correspond to the level of assessed risk
Document all clinical decisions and treatment plans

For additional resources on risk assessment, click here.

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Risk Assessment

Estimating Risk Levels

Documentation