Assessment tools of immediate risk of self-harm and suicide in children and young people: A scoping review

Abstract

There are increasing numbers of children presenting to paediatric hospital settings in mental health crisis. Typically, non-mental health professionals are responsible for the initial assessment of these children and are required to identify immediate physical and emotional health needs. To ensure the safety of these children, immediate risk of suicide and self-harm should be assessed. However, no standardized assessment tool is used in clinical practice, and for those tools that are used, their validity and reliability is unclear. A scoping review was conducted to identify the existing assessment tools of immediate self-harm and suicide risk. Searches of electronic databases and relevant reference lists were undertaken. Twenty-two tools were identified and most assessed acute risk of suicide with only four tools incorporating a self-harm assessment. The tools varied in number of items (4–146), subscales (0–11) and total scores (16–192). Half incorporated Likert-type scales, and most were completed via self-report. Many tools were subject to limited psychometric testing, and no single tool was valid or reliable for use with children presenting in mental health crisis to non-mental health settings. As such, a clinically appropriate, valid and reliable tool that assesses immediate risk of self-harm and suicide in paediatric settings should be developed.

Keywords

Children and young people risk assessment scoping review self-harm suicide

Introduction

Globally, the prevalence of mental health problems in children and young people (CYP) is increasing (Merikangas et al., 2009), with estimates of up to 10% of all CYP being clinically diagnosable (Green et al., 2005). These statistics represent a spectrum of conditions, requiring different levels of healthcare across primary and secondary care service settings.

At the acute end of this spectrum are CYP experiencing mental health crisis. This is defined as a psychiatric emergency involving ‘an acute disruption of psychological homeostasis whereby usual coping mechanisms fail and distress and functional impairment’ results (Lewis and Roberts, 2001). This may include extreme anxiety or panic attacks; psychotic episodes (including delusions, hallucinations, paranoia or hearing voices); hypomania or mania; other behaviours that feel out of control; and acts of suicide or self-harm (Mind, 2013).

There are varying definitions of both self-harm and suicide in the literature. However, for the purpose of this article, self-harm has been defined as an act with nonfatal outcome, in which an individual, irrespective of motivation, initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing desired changes (National Institute for Health and Clinical Excellence (NICE), 2013; Schmidtke et al., 1996).

Internationally, emergency department (ED) attendance for self-harm and suicidal behaviour is high (Bethell et al., 2013; Rhodes et al., 2014), with literature indicating that CYP presenting to the ED due to self-harm are likely to present again within the months following a previous presentation (Bennardi et al., 2016; Hulten et al., 2001). Suicide remains prevalent in CYP, with prevalence rates of 5.3 per 100,000 in 15–19-year-olds in the United Kingdom (Office of National Statistics, 2016). Moreover, 145 suicides of young people under the age of 20 were reported in England between 2014 and 2015 (Rodway et al., 2016). Mental health crisis is the primary cause of approximately 5% of ED attendances (Parsonage et al., 2012) with the most prevalent presenting conditions being self-harm or suicide behaviours. Moreover, in CYP aged 10–19 years in England, suicide prevalence is 4.3 per 100,000, and self-harm is 435.95 per 100,000, with repeat ED attendance becoming increasingly commonplace (Hawton et al., 2012).

In the United Kingdom, for CYP presenting to hospital in mental health crisis, initial assessment is often undertaken by non-mental health professionals (paediatricians or children’s nurses) within ED and paediatric ward settings (Anderson and Standen, 2007). This assessment aims to address immediate physical health needs (Olfson et al., 2005) and identify immediate risks to CYP’s safety while they await expert assessment by specialist mental health professionals.

Evidence suggests that risk assessments are no more accurate at predicting risk than expert specialist mental health professional clinical judgement in non-acute psychiatric outpatients (Quinlivan et al., 2017). However, acute paediatric care settings present specific differences in utility, focus and context that make the application of an assessment of suicide and self-harm unique. For example, the assessment is usually made by non-mental health experts who may lack specialist knowledge and experience to inform clinical decisions (Crawford et al., 2003). Furthermore, the focus of these assessments is to assess any immediate (i.e. hours or days) risks of self-harm or suicide while in receipt of acute paediatric care. Additionally, assessments are performed in time-limited circumstances with CYP with potentially dynamic and fluctuating mental health. Therefore, to enable implementation of a plan of care where immediate risks can be mitigated, healthcare professionals require appropriate support and guidance to inform their assessment. In the United Kingdom, the NICE (2004) guidelines advocate that CYP who self-harm should be assessed for risk. This assessment should identify the psychiatric illness and its relationship to self-harm, assess personal and social context and any specific factors predicting self-harm, and recognize any significant relationships that may be supportive or represent a threat. Such an assessment would need to consider the relatively immediate risk of self-harm or suicide in order to make time critical risk management decisions. Moreover, it would need to consider the developmental age of the CYP as children can often find verbal expression difficult, especially when in emotional distress (Vatne et al., 2010). Furthermore, the risk assessment should include assessment of previous ED presentations as this represents one of the strongest predictors of future ED repetitions across age and gender in young people (Bennardi et al., 2016; Hawton and James, 2005). Currently, however, there is no standardized assessment tool utilized in clinical practice in the United Kingdom, and for those that are used, their validity, reliability and acceptability remain questionable.

Aim

There is need for a scoping review exploring the breadth and psychometric properties of existing risk assessment tools of immediate risk of self-harm and suicide in CYP. The aim of this review is to scope the literature for existing assessment tools of immediate risk of self-harm and suicide in CYP and synthesize their characteristics and psychometric properties.

Method

A scoping review method adhering to a published framework (Arksey and O’Malley, 2005) was employed to guide evidence identification, data charting, collating, summarizing and reporting. Scoping reviews offer a transparent and systematic approach to reviewing literature and are particularly useful in research areas with emerging evidence bases and where the research questions go beyond intervention effectiveness (Arksey and O’Malley, 2005; Levac et al., 2010).

This scoping review employed a sequential two-phase approach. Phase 1 identified the assessment tools from the published literature. Phase 2 identified the psychometric testing papers for each assessment tool. Phases 1 and 2 involved searching four online databases (PubMed, MEDLINE, EMBASE and PsychINFO) and reference lists of included papers.

Search strategy

Phase 1 searches were conducted in November 2016. Predefined search terms and Boolean phrasing were used to identify assessment tools of immediate risk of self-harm or suicide (see Table 1).

Table 1.

Phase 1 search terms.

Population	Adolescen* OR Young people OR Child* OR Teenagers
Intervention	Suicid* OR suicidal behaviour OR suicide attempt OR suicidal ideation OR self harm* OR self-harm* OR deliberate self-harm	AND	Risk OR assessment OR screening

Phase 2 was conducted in May 2017. The assessment tool names identified from the phase 1 search were used to search each online bibliographic database to identify the psychometric testing papers for each assessment tool.

For both phases, the searches were saved and the references extracted into a reference management package (Mendeley™) for duplicate removal, followed by abstract and full-text eligibility screening.

Eligibility criteria

Inclusion criteria were (1) an assessment, scale or measure that assesses immediate suicide/self-harm risk; (2) validity/reliability testing of the assessment with CYP (aged 1–18 years); (3) English language publication; (4) full text accessible; (5) peer reviewed journal publication.

Exclusion criteria were (1) validity/reliability tested in adults only; (2) reported only in books/commentaries; (3) assessment is a subscale only; (4) assessment is a structured interview; (5) accessible as abstract only; (6) unpublished/grey literature; (7) the assessment tool is a screener of previous behaviour as opposed to an assessment tool of potential future behaviour.

Screening, data extraction and analysis

For products of search phases 1 and 2, each abstract and full text were screened for eligibility by two reviewers independently. Following identification of eligible full texts, data were charted, collated and summarized using the approach outlined by Arksey and O’Malley (2005). This involved one researcher (GMW) extracting data pertaining to the characteristics (including: focus of assessment, number of items, target population, completion and response formats) and psychometric properties (specifically reliability and validity) of the assessment tools into a table with predefined headings to ensure standardization of included data. Two researchers then agreed suitability and checked for accuracy (TC, JCM). This charted data were then collated and narratively summarized in relation to the risk assessment tool characteristics, and then their psychometric properties.

Findings

Phase 1 searches revealed 22 eligible full-text articles through which 26 risk assessment tools were identified. From these, 20 assessment tools met the eligibility criteria with reasons for exclusion shown in Figure 1. Phase 2 searches revealed two further assessment tools which met the eligibility criteria and were subsequently included in the review. The phase 2 searches also identified 62 papers that tested the reliability and validity of the 22 assessment tools (see Figure 2).

Figure 1.

Eligibility flow diagram for phase 1 search.

Figure 2.

Eligibility flow diagram for phase 2 search.

Overview of risk assessment tool characteristics

Please see Table 2 for the characteristicas of each seperate risk assessment tool. Most assessment tools assessed immediate risk of suicide only (18/22; 81%), with the remainder (4/22; 18%) incorporating a limited number of self-harm questions (Angelkovska, 2014; Horowitz et al., 2001; Pfeffer, 1986; Reynolds, 1990). The completion format for most of the assessment tools was self-report (13/22; 59%) (Conrad et al., 2009; Cotton and Range, 1996; Cull and Gill, 1982; Horowitz et al., 2001, 2012; Miller et al., 1986; Osman et al., 1998; Pfeffer et al., 2000; Plutchik et al., 1989; Range and Lewis, 1992; Reynolds, 1987a, 1987b; Shaffer et al., 2004), with the remainder being clinician-report (7/22; 32%) (Beck et al., 1974; Larzelere et al., 2004; Orbach et al., 1984, 1991; Pfeffer, 1986; Posner et al., 2011; Reynolds, 1990); parent report (1/22; 4.5%) (Angelkovska, 2014); or included provision for self, parent or clinician report (1/22; 4.5%) (Flamarique et al., 2016).

Table 2.

Assessment tool/scale characteristics.

Scale/tool	Focus of assessment	No. of items/subscales	Population tested (age; gender; ethnicity; diagnosis; setting; country)	Completion format	Response format
Adolescent Suicide Questionnaire (Horowitz et al., 2012)	Risk of suicidal behaviour	4 items	10–21-year-olds; male/females; mixed ethnicity; psychiatric, medical/surgical (Horowitz et al., 2012), young offenders (Stathis et al., 2008), Students (Allison et al., 1995); emergency department (Horowitz et al., 2012), detention centre (Stathis et al., 2008), school (Allison et al., 1995); United States (Horowitz et al., 2012), Australia (Allison et al., 1995; Stathis et al., 2008)	Self-report	Binary Yes/No/No response (missing data)Scores: 1–0Total score: 0–4Cut-off: score of 5
Child-Adolescent Suicide Potential Scale (Pfeffer, 1986)	Risk of suicidal behaviour	146 items and 11 subscales	5–12-year-olds; mixed ethnicity; psychiatric (Fennig et al., 2005; Ofek et al., 1998; Schwartz-Stav et al., 2006); inpatients (Fennig et al., 2005; Ofek et al., 1998; Schwartz-Stav et al., 2006); Israel (Fennig et al., 2005; Ofek et al., 1998; Schwartz-Stav et al., 2006)	Clinician-rated	Semi-structured interviewBinary: Yes/No (scores: 1–0)5-point Likert-type scale (scores: 1–5)3-point Likert-type scale (scores: 1–3)
Columbia Suicide Screen (Shaffer et al., 2004)	Risk of suicidal behaviour and ideation	11 items	11–18-year-olds; male/female; mixed ethnicity; suicidal (Miranda et al., 2014; Shaffer et al., 2004) and non-suicidal (Shaffer et al., 2004); schools (Miranda et al., 2014; Shaffer et al., 2004); United States (Miranda et al., 2014; Shaffer et al., 2004)	Self-report	5-point visual analogue scaleScores 1–5Total score: 1–55
Columbia Suicide Severity Rating Scale (Posner et al., 2011)	Severity and intensity of suicide risk	19 items and 4 subscales	11–17-year-olds; males/females; mixed ethnicity; suicide attempters (Knafo et al., 2015; Mirkovic et al., 2015; Posner et al., 2011), delinquents (Kerr et al., 2014), psychiatric (Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013; Flamarique et al., 2016; Horwitz et al., 2015; King et al., 2015; Knafo et al., 2015; Posner et al., 2011), medicated (Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013; Posner et al., 2011), non-psychiatric (King et al., 2015); outpatient (Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013; Flamarique et al., 2016), inpatient (Knafo et al., 2015; Mirkovic et al., 2015; Posner et al., 2011); emergency department (Horwitz et al., 2015; King et al., 2015), community (Kerr et al., 2014); Spain (Flamarique et al., 2016), United Kingdom (Flamarique et al., 2016), Italy (Flamarique et al., 2016), Germany (Atkinson et al., 2014; Emslie et al., 2015; Flamarique et al., 2016), Netherlands (Flamarique et al., 2016), United States (Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013; Horwitz et al., 2015; Kerr et al., 2014; King et al., 2015; Posner et al., 2011), South Africa (Atkinson et al., 2014; Emslie et al., 2015), Mexico (Emslie et al., 2014, 2015), Canada (Emslie et al., 2014, 2015), Argentina (Emslie et al., 2014, 2015), Estonia (Atkinson et al., 2014; Emslie et al., 2015), Finland (Atkinson et al., 2014; Emslie et al., 2015), Russia (Atkinson et al., 2014; Emslie et al., 2015), Slovakia (Atkinson et al., 2014; Emslie et al., 2015), Ukraine (Atkinson et al., 2014; Emslie et al., 2015), France (Atkinson et al., 2014; Emslie et al., 2015; Flamarique et al., 2016; Knafo et al., 2015; Mirkovic et al., 2015)	Clinician-rated	Semi-structured clinical interviewOrdinal scalesBinary: Yes/No scales3 Subscales (score: 0–5)1 Subscale (score: 0–6)1 Subscale (score 0–2); 3 open-endedTotal score: 0–44
Fairy Tales Test (Orbach et al., 1984)	Intensities of attitudes towards life and death	4 items	6–12-year-olds males/females; mixed ethnicity; suicidal (Orbach et al., 1984), chronically ill (Orbach et al., 1984), no health issues (Orbach et al., 1984); outpatients (Orbach et al., 1984), inpatients (Orbach et al., 1984), school (Orbach et al., 1984); United States (Orbach et al., 1984)	Clinician-rated	4-point Likert-type scaleScores 0–3 with a half-point intervalTotal score: 0–12
Life Orientation Inventory (Range and Lewis, 1992)	Intentions of suicide	113 items and 6 subscales	13–18-year-olds; mixed ethnicity; low proportion Native Americans (Range and Lewis, 1992), sixth-grade reading level (Range and Lewis, 1992), normal (Range and Lewis, 1992), students (Range and Lewis, 1992); outpatients (Range and Lewis, 1992), psychiatric inpatients (Range and Lewis, 1992), schools (Range and Lewis, 1992); United States (Range and Lewis, 1992)	Self-report	4-point Likert-type scale
Multi-Attitude Suicide Tendency scale (Orbach et al., 1991)	Suicidal tendencies and conflicting attitudes related to suicidality	30 items and 4 subscales	11–18-year-olds; males/females; mixed ethnicity; students (Orbach et al., 1991; Osman et al., 1993, 1994; Wong, 2004), non-referred (Osman et al., 1994), suicidal (Orbach et al., 1991), non-suicidal (Osman et al., 1993; Wong, 2004), suicide ideators (Osman et al., 1993; Wong, 2004), suicide attempters (Wong, 2004), non-suicidal self injurers (Ferrara et al., 2012), psychiatric (Ferrara et al., 2012; Orbach et al., 1991; Osman et al., 1994, 2000); normative (Orbach et al., 1991), parentally bereaved (Gutierrez, 1999); inpatients (Ferrara et al., 2012; Orbach et al., 1991; Osman et al., 1994, 2000); schools (Orbach et al., 1991; Osman et al., 1994; Wong, 2004), university (Osman et al., 1993), community (Gutierrez, 1999); United States (Gutierrez, 1999; Osman et al., 1993, 1994, 2000); Israel (Orbach et al., 1991); China (Wong, 2004), Italy (Ferrara et al., 2012)	Clinician-rated	5-point Likert-type scaleScores: 1–5Total score: 1–150
Reasons for living inventory for adolescents (Osman et al., 1998)	Adaptive reasons for not ending own life	32 items and 5 subscales	13–19-year-olds; males/females; mixed ethnicity; students (Labelle et al., 2015; Lee, 2011; Osman et al., 1998), psychiatric (Gutierrez et al., 2000; Labelle et al., 2015; Osman et al., 1998), suicide attempters (Gutierrez et al., 2000; Osman et al., 1998), non-suicidal (Gutierrez et al., 2000; Osman et al., 1998); inpatients (Gutierrez et al., 2000), outpatients (Labelle et al., 2015), school (Labelle et al., 2015; Lee, 2011; Osman et al., 1998), college (Osman et al., 1998); United States (Gutierrez et al., 2000; Osman et al., 1998), Korea (Lee, 2011), French (Labelle et al., 2015)	Self-report	6-point Likert-type scaleScores: 1–6Total score: 1–192Cut-off: 4.63
Risk of Suicide Questionnaire (Horowitz et al., 2001)	Suicide risk	14 items	11–16-year-olds; males/females; mixed ethnicity; psychiatric (Horowitz et al., 2001); emergency department (Horowitz et al., 2001); United States (Horowitz et al., 2001)	Self-report	Binary: Yes/No or No response (missing data)
Modified Scale for Suicide Ideation (Miller et al., 1986)	Suicide risk	18 items and 3 subscales	13–18-year-olds; male/female; mixed ethnicity; suicide attempters, suicide ideators, psychiatric; inpatients; United States (Pettit et al., 2009)	Self-report	4-point Likert-type scaleScores: 0–3Total score: 0–54
Self-Harm Risk Assessment for Children (Angelkovska, 2014)	Self-harm risk	33 items	6–12-year-olds; males/females; mixed ethnicity; behavioural/learning problems (Angelkovska et al., 2012), non-psychiatric (Angelkovska et al., 2012), non-clinical (Angelkovska et al., 2012), students (Angelkovska, 2014; Angelkovska et al., 2012); externalizers (Angelkovska et al., 2012), internalizers (Angelkovska et al., 2012), combined internalizers/externalizers (Angelkovska et al., 2012), self-harmers (Angelkovska, 2014), self-harm ideators (Angelkovska, 2014), clinic referred (Angelkovska, 2014), non-referred community comparisons (Angelkovska, 2014); outpatient (Angelkovska, 2014), community (Angelkovska et al., 2012), schools (Angelkovska, 2014); Australia (Angelkovska, 2014; Angelkovska et al., 2012)	Parent-rated	4-point Likert-type scaleScores: 1–4Binary: Yes/No
Suicidal Behaviours Questionnaire for Children (Cotton and Range, 1996)	Suicide risk	4 items	15–18-year-olds; males/females; mixed ethnicity; students, psychiatric; school, inpatients; United States (Cotton and Range, 1996)	Self-report	2-point, 4-point and 6-point Likert-type scalesTotal score: 0–16
Suicidal Ideation Questionnaire – Junior Version (Reynolds, 1987a)	Frequency and severity of suicidal ideation	15 items	11–18-year-olds; males/females; mixed ethnicity; students (Mazza, 2000; Mazza and Reynolds, 1999; Reynolds, 1990; Reynolds and Mazza, 2001), psychiatric (King et al., 1997, 2014; Mazza, 2000; Storch et al., 2014), suicide ideators (King et al., 2014), parentally bereaved (Gutierrez, 1999); inpatients (King et al., 1997, 2014), school (Mazza, 2000; Mazza and Reynolds, 1999; Reynolds, 1990; Reynolds and Mazza, 2001), outpatients (Storch et al., 2014), community (Gutierrez, 1999; Zhang et al., 2014); United States (Gutierrez, 1999; King et al., 1997, 2014; Mazza, 2000; Mazza and Reynolds, 1999; Reynolds, 1990; Reynolds and Mazza, 2001; Storch et al., 2014), China (Zhang et al., 2014)	Self-report	7-point Likert-type scale continuumScores: 0–6Total score: 0–90Cut-off: 31
Suicidal Ideation Questionnaire (Reynolds, 1987b)	Frequency and severity of suicidal ideation	30 items	13–19-year-olds; males/females; mixed ethnicity; students (Cho et al., 2008; Davis, 1992; Jia et al., 2015), suicide attempters (Shaunesey et al., 1993; Spirito et al., 1987, 1996), suicide ideators (Shaunesey et al., 1993), non-suicidal controls (Shaunesey et al., 1993) medical/surgical (Spirito et al., 1987; Stanley et al., 2013), psychiatric (Shaunesey et al., 1993; Stanley et al., 2013); inpatient (Shaunesey et al., 1993; Spirito et al., 1987, 1996), emergency department (Stanley et al., 2013), school (Cho et al., 2008; Davis, 1992; Jia et al., 2015), community (Zhang et al., 2014); United Kingdom, United States (Davis, 1992; Shaunesey et al., 1993; Spirito et al., 1987, 1996; Stanley et al., 2013), China (Jia et al., 2015; Zhang et al., 2014), Korea (Cho et al., 2008)	Self-report	7-point Likert-type scale continuumScores: 0–6Total score: 0–180Cut-off: 41
Suicide Behaviour Interview (Reynolds, 1990)	Suicide risk	22 items and 2 subscales	12–19-year-olds; males/females; mixed ethnicity; psychiatric; inpatients; United States (Mieczkowski et al., 1993)	Clinician-rated	Semi-structured interview0–2 or 0–4 point scaleScored to half a point (.5)2 open-ended questions
Suicide Intent Scale (Beck et al., 1974)	Suicide intent	20 items and 2 subscales	Children/adolescents (ages not defined); males/females; mixed ethnicity; psychiatric (Mieczkowski et al., 1993; Morano et al., 1993; Spirito et al., 1996), non-suicide attempters (Morano et al., 1993), suicide attempters (Mieczkowski et al., 1993; Morano et al., 1993; Spirito et al., 1996); inpatient (Mieczkowski et al., 1993; Morano et al., 1993; Spirito et al., 1996); United States (Mieczkowski et al., 1993; Morano et al., 1993; Spirito et al., 1996)	Clinician-rated	3-item Likert-type scaleScores: 1–3Total score: 1–60
Suicide Probability Scale (Cull and Gill, 1982)	Suicide risk	36 items and 4 subscales	>14 years old; males/females; mixed ethnicity; psychiatric (Eltz et al., 2007; Rosenberg et al., 2006), suicide attempters (Larzelere et al., 1996), suicide non-attempters (Larzelere et al., 1996), burn survivors (Rosenberg et al., 2006), physical abuse (Badura Brack et al., 2012), sexual abuse (Badura Brack et al., 2012), physical and sexual abuse (Badura Brack et al., 2012), no abuse (Badura Brack et al., 2012), medicated (Badura Brack et al., 2012); inpatient (Eltz et al., 2007), outpatients (Rosenberg et al., 2006), residential facility (Badura Brack et al., 2012; Larzelere et al., 1996); United States (Badura Brack et al., 2012; Eltz et al., 2007; Larzelere et al., 1996; Rosenberg et al., 2006)	Self-report	4-point Likert-type scale
Suicide Risk Scale (Plutchik et al., 1989)	Suicide risk	15 items and 4 subscales	12–18-year-olds; male/female; mixed ethnicity; psychiatric, abused, non-abused, depressed; inpatients; United States (Grilo et al., 1999)	Self-report	Binary: True/False
Child-Adolescent Suicidal Potential Index (Pfeffer et al., 2000)	Suicide risk	30 items and 3 subscales	6–17-year-olds; males/females; mixed ethnicity; psychiatric (Koutek et al., 2016; Pfeffer et al., 2000), students (Pfeffer et al., 2000), eating disorders (Koutek et al., 2016), suicide attempters (Pfeffer et al., 2000), suicide ideators (Pfeffer et al., 2000), assaulters/ideators (Pfeffer et al., 2000); inpatients (Koutek et al., 2016; Pfeffer et al., 2000); schools (Pfeffer et al., 2000); United States (Pfeffer et al., 2000), Czech Republic (Koutek et al., 2016)	Self-report	Binary: Yes/NoScores: 1–0Total score: 0–30Cut-off: 11
Child Suicide Risk Assessment (Larzelere et al., 2004)	Suicide risk	20 items and 3 subscales	6–12-year-olds; females/males; mixed ethnicity; suicide attempters and non-attempters (Larzelere et al., 2004); residential facility (Larzelere et al., 2004), foster care (Larzelere et al., 2004); United States (Larzelere et al., 2004)	Clinician-rated	Binary: Yes/NoCut-off score: 8
Suicide Status Form-II (Conrad et al., 2009)	Suicide risk and frequency of suicidal ideation	6 items	8–18-year-olds; males/females; mixed ethnicity; psychiatric (Mcnicholas, 2011; Romanowicz et al., 2013), suicide attempters (Romanowicz et al., 2013), suicide ideators (Romanowicz et al., 2013); inpatient (Mcnicholas, 2011; Romanowicz et al., 2013); United States (Mcnicholas, 2011; Romanowicz et al., 2013)	Self-report	5-point Likert-type scaleScores: 1–52 Binary Yes/No
Suicidality Treatment Occurring Paediatrics – Suicidality Assessment Scale (Flamarique et al., 2016)	Suicide risk	14 items – children19 items –adolescent, parents and clinician	8–18-year-olds; males/females; mixed ethnicity; psychiatric (Flamarique et al., 2016), medicated (Flamarique et al., 2016); outpatients (Flamarique et al., 2016); Spain (Flamarique et al., 2016), United Kingdom (Flamarique et al., 2016), Italy (Flamarique et al., 2016), France (Flamarique et al., 2016), Germany (Flamarique et al., 2016), Netherlands (Flamarique et al., 2016)	Self-report; parent- report; clinician-report	6-point Likert-type scaleAdolescents, parents and clinicians: 0–5 scoresTotal score: 0–954-point Likert-type scaleChildren: 0–3 scoresTotal score: 0–42

The assessment tools varied in relation to the number of items/questions (range: 4–146); subscales (range: 0–11); and maximum total score (range: 16–192), with less than half of the assessment tools not reporting total scores (9/22; 41%) (Angelkovska, 2014; Conrad et al., 2009; Cull and Gill, 1982; Horowitz et al., 2001; Larzelere et al., 2004; Plutchik et al., 1989; Range and Lewis, 1992; Reynolds, 1990; Shaffer et al., 2004). The assessment tools varied in response format with a mixture of Likert-type scale only (11/22; 50%) (Beck et al., 1974; Cotton and Range, 1996; Cull and Gill, 1982; Flamarique et al., 2016; Miller et al., 1986; Orbach et al., 1984, 1991; Osman et al., 1998; Range and Lewis, 1992; Reynolds, 1987b, 1987a); binary only (6/22; 27%) (Conrad et al., 2009; Horowitz et al., 2001, 2012; Larzelere et al., 2004; Pfeffer et al., 2000; Plutchik et al., 1989); mixed response (4/22; 27.5%) (Angelkovska, 2014; Pfeffer, 1986; Posner et al., 2011; Reynolds, 1990); and visual analogue scales (1/22; 4.5%) (Shaffer et al., 2004).

All included assessment tools were psychometrically tested in at least one subsequent testing paper. The Columbia Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2011) was the most rigorously studied, with 11 subsequent psychometric testing papers (Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013; Flamarique et al., 2016; Horwitz et al., 2015; Kerr et al., 2014; King et al., 2015; Knafo et al., 2015; Mirkovic et al., 2015; Posner et al., 2011).

Overview of psychometric testing

Psychometric testing across the assessment tools was undertaken on mixed ethnicities and populations aged 5–19 years (Online Supplemental Tables 3 and 4). It was also undertaken across various settings, including inpatient hospitals (14/22; 63.6%) (Cotton and Range, 1996; Eltz et al., 2007; Fennig et al., 2005; Ferrara et al., 2012; Grilo et al., 1999; Gutierrez et al., 2000; Knafo et al., 2015; Koutek et al., 2016; Mcnicholas, 2011; Mieczkowski et al., 1993; Mirkovic et al., 2015; Morano et al., 1993; Ofek et al., 1998; Orbach et al., 1984, 1991; Osman et al., 1994, 2000; Pettit et al., 2009; Pfeffer et al., 2000; Posner et al., 2011; Range and Lewis, 1992; Romanowicz et al., 2013; Schwartz-Stav et al., 2006; Shaunesey et al., 1993; Spirito et al., 1987, 1996); schools (13/22; 59.1%) (Allison et al., 1995; Angelkovska, 2014; Cho et al., 2008; Cotton and Range, 1996; Davis, 1992; Jia et al., 2015; Labelle et al., 2015; Lee, 2011; Mazza, 2000; Mazza and Reynolds, 1999; Miranda et al., 2014; Orbach et al., 1984, 1991; Osman et al., 1994, 1998; Pfeffer et al., 2000; Range and Lewis, 1992; Reynolds, 1990; Reynolds and Mazza, 2001; Shaffer et al., 2004; Wong, 2004); universities (1/22; 4.5%) (Osman et al., 1993); outpatient departments (9/22; 40.9%) (Angelkovska, 2014; Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013; Flamarique et al., 2016; King et al., 1997, 2014; Labelle et al., 2015; Orbach et al., 1984; Range and Lewis, 1992; Rosenberg et al., 2006; Storch et al., 2014); EDs (4/22; 18.2%) (Horowitz et al., 2001, 2012; Horwitz et al., 2015; King et al., 2015; Stanley et al., 2013); non-hospital community settings (3/22; 13.6%) (Angelkovska et al., 2012; Gutierrez, 1999; Kerr et al., 2014; Zhang et al., 2014); detention centres (1/22; 4.5%) (Stathis et al., 2008); foster care settings (1/22; 4.5%) (Larzelere et al., 2004); and residential facility/home settings (3/22; 13.6%) (Badura Brack et al., 2012; Larzelere et al., 2004; Larzelere et al., 1996).

Most psychometric testing papers were undertaken in English-speaking populations in the United States; 45/62; 72.6%). Several were tested in non-English language translation, as follows: Hebrew (4/22; 18.2%) (Fennig et al., 2005; Ofek et al., 1998; Orbach et al., 1991; Schwartz-Stav et al., 2006); Chinese (3/22; 13.6%) (Jia et al., 2015; Wong, 2004; Zhang et al., 2014); Korean (2/22; 9.0%) (Lee, 2011; Cho et al., 2008); French (4/22; 18.2%) (Flamarique et al., 2016; Knafo et al., 2015; Labelle et al., 2015; Mirkovic et al., 2015), German (1/22; 4.5%) (Flamarique et al., 2016); Dutch (1/22; 4.5%) (Flamarique et al., 2016); Italian (2/22; 9.0%) (Ferrara et al., 2012; Flamarique et al., 2016); and Spanish (1/22; 4.5%) (Flamarique et al., 2016).

Face validity

Face validity was tested with varying degrees of rigour for five (22.7%) assessment tools (Flamarique et al., 2016; Larzelere et al., 2004; Mieczkowski et al., 1993; Pfeffer et al., 2000; Range and Lewis, 1992). The Suicide Intent Scale (Mieczkowski et al., 1993) reported face validity without description of method or outcome. The Life Orientation Inventory (LOI) items were reviewed by psychologists and previously suicidal individuals (Range and Lewis, 1992). The Child Suicide Risk Assessment (CSRA) (Larzelere et al., 2004) items were reviewed by children, and it was found that 85% of the items were understood well. The Suicidality Treatment Occurring Paediatrics – Suicidality Assessment Scale (STOP-SAS) (Flamarique et al., 2016) reported child feedback of item comprehension and problems differentiating items, consequently a process of re-wording, sentence shortening and children’s suggested examples were incorporated into the scale. The Child-Adolescent Suicidal Potential Index (Pfeffer et al., 2000) was reviewed by psychiatric professionals leading to revision of instructions, items and response formats. Children’s suggested changes to wording comprehension were also implemented.

Predictive validity

Predictive validity was tested for 19 assessment tools (86.4%). Methods of predictive validity were as follows: first, assessment score correlations with actual events (such as past, present or future suicide/self-harm thoughts or behaviours; 14/22; 63.6%) (Eltz et al., 2007; Fennig et al., 2005; Ferrara et al., 2012; Flamarique et al., 2016; Gutierrez et al., 2000; Horwitz et al., 2015; Kerr et al., 2014; King et al., 2014, 2015; Koutek et al., 2016; Larzelere et al., 2004; Larzelere et al., 1996; Mieczkowski et al., 1993; Miranda et al., 2014; Osman et al., 2000; Pfeffer et al., 2000; Posner et al., 2011; Reynolds, 1990; Zhang et al., 2014); second, sensitivity and specificity (13/22; 59.1%) (Flamarique et al., 2016; Gutierrez et al., 2000; Horowitz et al., 2001, 2012; King et al., 2015; Larzelere et al., 2004; Larzelere et al., 1996; Osman et al., 1994, 2000; Pfeffer et al., 2000; Posner et al., 2011; Shaffer et al., 2004; Stathis et al., 2008; Zhang et al., 2014); and third, the proportion of positive and negative findings that were true positive and true negative results, that is, positive predictive value (PPV) and negative predictive value (NPV; 8/22; 36.4%) (Horowitz et al., 2001, 2012; Koutek et al., 2016; Larzelere et al., 2004; Larzelere et al., 1996; Shaffer et al., 2004; Zhang et al., 2014). The C-SSRS (Posner et al., 2011) had predictive validity most rigorously tested (four psychometric testing papers) (Horwitz et al., 2015; Kerr et al., 2014; King et al., 2015; Posner et al., 2011).

Eight assessment tools (36.4%) consistently predicted suicide/self-harm events (Eltz et al., 2007; Flamarique et al., 2016; Grilo et al., 1999; Gutierrez et al., 2000; Koutek et al., 2016; Larzelere et al., 1996; Miranda et al., 2014; Pfeffer et al., 2000; Reynolds, 1990; Zhang et al., 2014); five (22.7%) predicted suicide/self-harm variably (Fennig et al., 2005; Ferrara et al., 2012; Horwitz et al., 2015; Kerr et al., 2014; King et al., 2014, 2015; Larzelere et al., 2004; Osman et al., 2000; Posner et al., 2011; Zhang et al., 2014); and one (4.5%) did not predict suicide/self-harm (Mieczkowski et al., 1993).

Sensitivity and specificity testing across the studies revealed substantial variability suggesting that although these scales were able to identify those at risk they were also likely to classify some individuals’ as at risk when they were not. The C-SSRS, the Suicide Ideation Questionnaire-Junior and the Suicide Ideation Questionnaire had the highest sensitivity ratings suggesting they are the most likely to be able to identify those at risk of engaging in suicidal or self-harming behaviour.

Total-item PPVs were performed for 6/22 (27.2%) assessment tools (Cull and Gill, 1982; Horowitz et al., 2012; Larzelere et al., 2004; Reynolds, 1987a, 1987b; Shaffer et al., 2004) and NPVs were performed for 3/22 (13.6%) assessment tools (Horowitz et al., 2012; Larzelere et al., 2004; Shaffer et al., 2004). Total-item PPVs were variable across studies (range: 8.8–71.3%) (Horowitz et al., 2012; Larzelere et al., 2004; Larzelere et al., 1996; Shaffer et al., 2004; Zhang et al., 2014) as was total-item NPVs (range: 13.6–99.7%) (Horowitz et al., 2012; Larzelere et al., 2004; Shaffer et al., 2004). The Suicide Probability Scale (SPS) (Cull and Gill, 1982) had the lowest PPV (Larzelere et al., 1996) and the CSRA (Larzelere et al., 2004) had the lowest NPV. The Adolescent Suicide Questionnaire (Horowitz et al., 2012) had the highest PPV and NPV.

Convergent validity

Convergent validity, that is, the degree to which two measures should theoretically correlate, was tested for 19 (86.4%) assessment tools, all of which tested total-item convergent validity. Subscale convergent validity was tested in 10/22 (45.5%) of the assessment tools (Beck et al., 1974; Cotton and Range, 1996; Cull and Gill, 1982; Horowitz et al., 2001; Larzelere et al., 2004; Orbach et al., 1991; Osman et al., 1998; Pfeffer, 1986; Pfeffer et al., 2000; Posner et al., 2011). Correlations between assessments and construct measures were variable. Five assessment tools (22.7%) failed to demonstrate significant correlations between all subscales and construct measures (Cotton and Range, 1996; Ferrara et al., 2012; Gutierrez, 1999; Mieczkowski et al., 1993; Ofek et al., 1998; Orbach et al., 1991; Osman et al., 1994, 2000; Rosenberg et al., 2006; Spirito et al., 1996). Furthermore, four assessment tools failed to correlate total-item scores with some construct measures (18.2%) (Grilo et al., 1999; Pettit et al., 2009; Rosenberg et al., 2006; Storch et al., 2014). The Multi-Attitude Suicide Tendency (MAST) scale had convergent validity most rigorously tested in six psychometric testing papers (Ferrara et al., 2012; Gutierrez, 1999; Orbach et al., 1991; Osman et al., 1994, 2000; Wong, 2004).

Discriminant validity (between groups)

Discriminant validity was tested for 20 (90.1%) assessment tools, of which 16 (72.7%) tested total-item subscale discriminant validity (Angelkovska, 2014; Beck et al., 1974; Conrad et al., 2009; Cotton and Range, 1996; Cull and Gill, 1982; Horowitz et al., 2012; Larzelere et al., 2004; Orbach et al., 1991; Osman et al., 1998; Pfeffer et al., 2000; Plutchik et al., 1989; Posner et al., 2011; Range and Lewis, 1992; Reynolds, 1987a, 1987b; Reynolds, 1990), and 9 (40.9%) tested subscale discriminant validity (Conrad et al., 2009; Cull and Gill, 1982; Miller et al., 1986; Orbach et al., 1984, 1991; Osman et al., 1998; Pfeffer et al., 2000; Posner et al., 2011; Reynolds, 1990). Numerous demographic and characteristic domains were also tested, and some assessment tools were consistently able to discriminate between age (2/22; 9.0%) (Pfeffer et al., 2000; Reynolds, 1990); gender (2/22; 9.0%) (Horwitz et al., 2015; Pfeffer et al., 2000); psychiatric diagnosis (6/22; 27.3%) (Knafo et al., 2015; Mazza, 2000; Range and Lewis, 1992; Schwartz-Stav et al., 2006; Spirito et al., 1987, 1996); suicide and self-harm status (10/22; 45.5%) (Grilo et al., 1999; Gutierrez et al., 2000; Horwitz et al., 2015; King et al., 2015; Larzelere et al., 2004; Lee, 2011; Morano et al., 1993; Osman et al., 1998; Range and Lewis, 1992; Reynolds, 1990; Romanowicz et al., 2013; Shaunesey et al., 1993; Spirito et al., 1987, 1996); physical illness status (2/22; 9.0%) (Angelkovska, 2014; Spirito et al., 1996); accidental injury (1/22; 4.5%) (Rosenberg et al., 2006); and family history of suicide (1/22; 4.5%) (Romanowicz et al., 2013). Some assessment tools consistently failed to discriminate for age (3/22; 13.6%) (Romanowicz et al., 2013; Spirito et al., 1987, 1996; Zhang et al., 2014); gender (3/22; 13.6%) (Allison et al., 1995; Grilo et al., 1999; Spirito et al., 1996); psychiatric diagnosis (2/22; 9.0%) (Grilo et al., 1999; Rosenberg et al., 2006); and history of abuse (1/22; 4.5%) (Grilo et al., 1999). The C-SSRS (Posner et al., 2011) was most rigorously tested for discriminant validity (eight psychometric testing papers) (Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013; Horwitz et al., 2015; King et al., 2015; Knafo et al., 2015; Mirkovic et al., 2015).

Internal consistency

Internal consistency was tested for 17/22 (77.3%) assessment tools (Angelkovska, 2014; Beck et al., 1974; Cull and Gill, 1982; Flamarique et al., 2016; Horowitz et al., 2012; Larzelere et al., 2004; Miller et al., 1986; Orbach et al., 1991; Osman et al., 1998; Pfeffer et al., 2000; Pfeffer, 1986; Plutchik et al., 1989; Posner et al., 2011; Range and Lewis, 1992; Reynolds, 1987a, 1987b; Reynolds, 1990). Total-item internal consistency (range: α = .60–.99) was higher and less variable overall than subscale internal consistency (range: .38–.95). Therefore, when taken as a whole, the scales demonstrate better internal consistency and less fluctuation than when exploring between subscales. The Suicidal Ideation Questionnaire – Junior Version (SIQ-JR) (Reynolds, 1987a) achieved the highest internal consistency (r = .99) (Gutierrez, 1999). The MAST scale (Orbach et al., 1991) was most rigorously tested for internal consistency (five psychometric testing papers) (Gutierrez, 1999; Orbach et al., 1991; Osman et al., 1994, 2000; Wong, 2004).

Inter-rater reliability

Inter-rater reliability was tested for 4/22 (18.2%) assessment tools (Flamarique et al., 2016; Pfeffer, 1986; Posner et al., 2011; Reynolds, 1990). These assessment tools were subjected to total-item inter-rater reliability (2/22; 9.0%) (Flamarique et al., 2016; Reynolds, 1990) and subscale inter-rater reliability (2/22; 9.0%) (Fennig et al., 2005; Kerr et al., 2014; Ofek et al., 1998). Total-item inter-rater analyses revealed variable correlations (range: .47 to .99) as did the subscale inter-rater analyses (range: .40–.97). The Suicide Behaviour Interview had the highest inter-rater reliability (intraclass correlation coefficient = .99) (Reynolds, 1990) and the STOP-SAS had the lowest (r = .47) (Flamarique et al., 2016). The Child-Adolescent Suicide Potential Scale (Pfeffer, 1986) had inter-rater reliability most rigorously tested (two psychometric testing papers) (Fennig et al., 2005; Ofek et al., 1998).

Test-retest reliability

Test-retest reliability was tested for 7/22 (31.8%) assessment tools, demonstrating variable reliability (range: r = .32–.92) (Cull and Gill, 1982; Orbach et al., 1984; Pfeffer, 1986; Pfeffer et al., 2000; Range and Lewis, 1992; Reynolds, 1987a; Shaffer et al., 2004). Three (14%) assessment tools reported subscale test-retest reliability, with less variability (r = .39–.78), suggesting these scales have some ability to remain consistent over time (Ofek et al., 1998; Orbach et al., 1984; Pfeffer et al., 2000). The SPS and LOI (r = .92) (Larzelere et al., 1996; Range and Lewis, 1992) had the highest test-retest reliability and the Columbia Suicide Screen had the lowest (r = .32) (Shaffer et al., 2004). 1/22 (4.5%) The Fairy Tales Test assessment tool (Orbach et al., 1984) failed to achieve test-retest reliability for all questions.

Discussion

The assessment tools included in this review varied in length, response and scoring format, age ranges and degree of psychometric testing. Most assessments were tested across broad age ranges, and may be criticized as lacking developmental sensitivity. The SIQ and the SIQ-JR, however, were exceptions, having undergone age-based revisions/adaptations. Some measures of suicide risk incorporated risk items relating to self-harm. No measure assessed risk of self-harm in isolation. Most assessment tools were tested only in the United States and primarily with inpatients, in contrast to cross-cultural psychometric guidelines (Beaton et al., 2000). Few papers reported language translations and none reported cultural adaptations. Most assessment tools were originally developed in the English language, but few reported psychometric testing in UK populations, suggesting limited applicability in acute paediatric settings in this region. As such, it is understandable that UK guidelines do not promote the use of any one assessment tool to safely manage immediate risk of self-harm or suicide to inform clinical decisions in acute paediatric settings (Horowitz et al., 2014).

Across the included tools, internal consistency and test-retest reliability was generally moderate to good, suggesting that many are constructed of items that are likely to measure the same construct (i.e. risk of suicide) and that the tools are able to produce similar scores when tested over a number of time points, respectively. Test-retest reliability was, however, variable across many of the studies and may be due to suicide/self-harm risk being sensitive to change.

Only four assessments (Flamarique et al., 2016; Pfeffer, 1986; Posner et al., 2011; Reynolds, 1990) investigated inter-rater reliability, thus we have little evidence that the current assessment tools provide consistent results across different raters. Moreover, for those tools for which this testing was undertaken, it appears the majority were tested with raters (i.e. clinician, self and parent) with limited scientific or clinical justification.

Although face validity is considered the weakest validity test (Devon et al., 2007), it is typically considered a prerequisite before performing other validity/reliability tests (Devon et al., 2007). However, few studies tested it, and those that had, lacked strong methodological report, thus reducing the potential usefulness for the tools, and limiting the ability to replicate procedures (Schulz et al., 2010). Moreover, there appears to be limited consideration to the developmental issues within the tools included in this review. As such, considering the substantial differences in cognitive ability, perception and understanding between younger children and those closer to 18 years of age, the current tools appear unable to provide accurate representation of potential risk for CYP across the age range.

This review highlights that the majority of previous assessment tools of immediate risk of self-harm and/or suicide have not been tested to levels recommended by psychometric guidelines (Devon et al., 2007). Moreover, several of these assessment tools demonstrate inconsistent validity and reliability ratings across different testing studies. Additionally, cut-off values denoting high-risk scores are sparsely defined thus limiting their clinical utility as such values can be a useful adjunct to suicide risk assessment in non-psychiatric emergency settings (Cochrane-Brink et al., 2000). Several assessment tools were only tested in one subsequent psychometric testing paper, highlighting limited testing across the majority of the assessment tools. An exception is the C-SSRS which generally performed well across multiple psychometric domains and has been used to monitor medication safety in clinical practice (Atkinson et al., 2014; Emslie et al., 2014, 2015; Findling et al., 2013).

The findings from this scoping review stem from an extensive, transparent search of the literature and provide a summary of the characteristics, and ratings of reliability and validity of assessments tools of immediate self and suicide risk in CYP. This is a scoping review however, and as such it cannot be concluded with certainty that additional risk assessment tools have not been developed and psychometrically tested. Moreover, use of only the terms ‘self-harm’ and ‘deliberate self-harm’ in the search strategy represents a potential limitation, as other additional studies may have identified the behaviour using alternative terminology.

However, the review has identified key gaps and deficits including limited immediate self-harm risk assessment tools for CYP, limited psychometric testing of current assessment tools in specific contexts and regions, and no one assessment tool having been fully validated in an inpatient paediatric setting.

Thus, there are clear implications for clinical practice as currently there appears to be no suicide/self-harm risk assessment tool validated for use in inpatient paediatric settings where there may be an immediate risk of self-harm or suicidal behaviour (i.e. within hours of the triage assessment). As a result, healthcare professionals working within paediatric inpatient settings have to resort to using their own clinical judgement (which may be based on minimal experience and training) or a risk assessment framework/tool that has not been developed for the specific needs of this population/setting. Consequently, this may lead to an inaccurate assessment of risk potentially resulting in either over or under estimation of risk rating, and subsequent inappropriate safety management strategies being utilized.

Considering the increasing prevalence of mental health problems in CYP, and the paucity in existing risk assessments outlined here, future research should be focused on the development of a clinically appropriate, psychometrically tested assessment tool of immediate risk of self-harm and suicide behaviour for CYP. This assessment tool could then be used to support safety management decisions across acute paediatric care settings.

Supplemental Material

Supplemental_Table_3 - Assessment tools of immediate risk of self-harm and suicide in children and young people: A scoping review

Supplemental_Table_3 for Assessment tools of immediate risk of self-harm and suicide in children and young people: A scoping review by Tim Carter, Gemma M Walker, Aimee Aubeeluck and Joseph C Manning in Journal of Child Health Care

Supplemental Material

Supplemental_Table_4 - Assessment tools of immediate risk of self-harm and suicide in children and young people: A scoping review

Supplemental_Table_4 for Assessment tools of immediate risk of self-harm and suicide in children and young people: A scoping review by Tim Carter, Gemma M Walker, Aimee Aubeeluck and Joseph C Manning in Journal of Child Health Care

Footnotes

Authors’ note

TC and JCM designed the scoping review protocol. GMW wrote the initial draft of the manuscript. TC, AA and JCM revised, edited and finalized the manuscript. TC, JCM and GMW conducted the database searches, confirmed included papers and agreed data extraction. All authors agreed the final manuscript for publication. The views represented are the views of the authors alone and do not necessarily represent the views of the Nottinghamshire Clinical Commissioning Group or Nottingham University Hospitals NHS Trust.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Nottinghamshire Clinical Commissioning Group and Nottingham University Hospitals NHS Trust sponsorship.

ORCID iD

Tim Carter

Joseph C Manning

Supplemental Material

Supplemental material for this article is available online.

References

Allison

Pearce

Martin

. (1995) Parental influence, pessimism and adolescent suicidality. Archives of Suicide Research 1(4): 229–242.

Anderson

Standen

(2007) Attitudes towards suicide among nurses and doctors working with children and young people who self-harm. Journal of Psychiatric and Mental Health Nursing 14(5): 470–477.

Angelkovska

(2014) The development and validation of an instrument to identify risk of self-harm in children. Available at: http://research-repository.uwa.edu.au/files/3236726/Angelkovska_Agni_2007.pdf (accessed 25 June 2017).

Angelkovska

Houghton

Hopkins

(2012) Differential profiles of risk of self-harm among clinically referred primary school aged children. School Psychology International 33(6): 646–660.

Arksey

O’Malley

(2005) Scoping studies: framework, towards a methodological. International of Social Research Methodology 8(1): 19–32.

Atkinson

Prakash

Zhang

. (2014) A double-blind efficacy and safety study of duloxetine flexible dosing in children and adolescents with major depressive disorder. Journal of Child and Adolescent Psychopharmacology 24(4): 180–189.

Badura Brack

Huefner

Handwerk

. (2012) The impact of abuse and gender on psychopathology, behavioral disturbance, and psychotropic medication count for youth in residential treatment. American Journal of Orthopsychiatry 82(4): 562–572.

Beaton

Bombardier

Guillemin

. (2000) Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 25(24): 3186–3191.

Beck

Schuyler

Herman

(1974) Development of suicidal intent scales. In: Beck

Resnik

Lettieri

(eds.) The Prediction of Suicide. Oxford: Charles Press Publishers, pp. 45–56.

10.

Bennardi

McMahon

Corcoran

. (2016) Risk of repeated self-harm and associated factors in children, adolescents and young adults. BMC Psychiatry 16(1): 421–433.

11.

Bethell

Bondy

Wendy Lou

. (2013) Emergency department presentations for self-harm among Ontario youth. Canadian Journal of Public Health 104(2): e124–e130.

12.

Cho

Kim

Choi

. (2008) Associations between symptoms of attention deficit hyperactivity disorder, depression, and suicide in Korean female adolescents. Depression and Anxiety 25(11): E142–E146.

13.

Cochrane-Brink

Lofchy

Sakinofsky

(2000) Clinical rating scales in suicide risk assessment. General Hospital Psychiatry 22(6): 445–451.

14.

Conrad

Jacoby

Jobes

. (2009) A psychometric investigation of the suicide status Form II with a psychiatric inpatient sample. Suicide & Life-threatening Behavior 39(3): 307–320.

15.

Cotton

Range

(1996) Suicidality, hopelessness, and attitudes toward life and death in clinical and nonclinical adolescents. Death Studies, Taylor & Francis Group 20(6): 601–610.

16.

Crawford

Geraghty

Street

. (2003) Staff knowledge and attitudes towards deliberate self-harm in adolescents. Journal of Adolescence 26(5): 619–629.

17.

Cull

Gill

(1982) Suicide Probability Scale. Western Psychological Services. Los Angeles: WPS.

18.

Davis

(1992) Suicidal Ideation Questionnaire. Journal of Psychoeducational Assessment. Odessa: Psychological Assessment Resources.

19.

Devon

Block

Moyle-Wright

. (2007) A psychometric toolbox for testing validity and reliability. Journal of Nursing Scholarship 39(2): 155–164.

20.

Eltz

Evans

Celio

. (2007) Suicide Probability Scale and its utility with adolescent psychiatric patients. Child Psychiatry and Human Development 38(1): 17–29.

21.

Emslie

Prakash

Zhang

. (2014) A double-blind efficacy and safety study of duloxetine fixed doses in children and adolescents with major depressive disorder. Journal of Child and Adolescent Psychopharmacology 24(4): 170–179.

22.

Emslie

Wells

Prakash

. (2015) Acute and longer-term safety results from a pooled analysis of duloxetine studies for the treatment of children and adolescents with major depressive disorder. Journal of Child and Adolescent Psychopharmacology 25(4): 293–305.

23.

Fennig

Geva

Zalsman

. (2005) Effect of gender on suicide attempters versus nonattempters in an adolescent inpatient unit. Comprehensive Psychiatry 46(2): 90–97.

24.

Ferrara

Terrinoni

Williams

(2012) Non-suicidal self-injury (Nssi) in adolescent inpatients: assessing personality features and attitude toward death. Child and Adolescent Psychiatry and Mental Health 6(1): 12.

25.

Findling

Robb

Bose

(2013) Escitalopram in the treatment of adolescent depression: a randomized, double-blind, placebo-controlled extension trial. Journal of Child and Adolescent Psychopharmacology 23(7): 468–480.

26.

Flamarique

Santosh

Zuddas

. (2016) Development and psychometric properties of the Suicidality: Treatment Occurring in Paediatrics (STOP) Suicidality Assessment Scale (STOP-SAS) in children and adolescents. BMC Pediatrics 16(1): 213.

27.

Green

McGinnity

Meltzer

. (2005) Mental health of children and young people in Great Britain. Available at: http://www.esds.ac.uk/doc/5269/mrdoc/pdf/5269technicalreport.pdf (accessed 25 May 2017).

28.

Grilo

Sanislow

Fehon

. (1999) Psychological and behavioral functioning in adolescent psychiatric inpatients who report histories of childhood abuse. American Journal of Psychiatry 156(4): 538–543.

29.

Gutierrez

(1999) Suicidality in parentally bereaved adolescents. Death Studies 23(4): 359–370.

30.

Gutierrez

Osman

Kopper

. (2000) Why young people do not kill themselves: the reasons for living inventory for adolescents. Journal of Clinical Child Psychology 29(2): 177–187.

31.

Hawton

James

(2005) ABC of adolescence: suicide and deliberate self harm in young people. British Medical Journal 330(7496): 891–894.

32.

Hawton

Bergen

Kapur

. (2012) Repetition of self-harm and suicide following self-harm in children and adolescents: findings from the multicentre study of self-harm in England. Journal of Child Psychology and Psychiatry and Allied Disciplines 53(12): 1212–1219.

33.

Horowitz

Bridge

Pao

. (2014) Screening youth for suicide risk in medical settings: time to ask questions. American Journal of Preventive Medicine 47(3 suppl 2): S170–S175.

34.

Horowitz

Bridge

Teach

. (2012) Ask Suicide-Screening Questions (ASQ). Archives of Pediatrics & Adolescent Medicine 166(12): 1170–1176.

35.

Horowitz

Wang

Koocher

. (2001) Detecting suicide risk in a pediatric emergency department: development of a brief screening tool. Pediatrics 107(5): 1133–1137.

36.

Horwitz

Czyz

King

(2015) Predicting future suicide attempts among adolescent and emerging adult psychiatric emergency patients. Journal of Clinical Child and Adolescent Psychology 44(5): 751–761.

37.

Hulten

Jiang

Wasserman

. (2001) Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors. European Child & Adolescent Psychiatry 10(3): 161–169.

38.

Jia

Wang

Zhao

(2015) Psychometric properties of the suicidal ideation questionnaire among Chinese high school students. OMEGA-Journal of Death and Dying 70(2): 195–207.

39.

Kerr

DCR

Gibson

Leve

. (2014) Young adult follow-up of adolescent girls in juvenile justice using the Columbia Suicide Severity Rating Scale. Suicide and Life-Threatening Behavior 44(2): 113–129.

40.

King

Berona

Czyz

. (2015) Identifying adolescents at highly elevated risk for suicidal behavior in the emergency department. Journal of Child and Adolescent Psychopharmacology 25(2): 100–108.

41.

King

Jiang

Czyz

. (2014) Suicidal ideation of psychiatrically hospitalized adolescents has one-year predictive validity for suicide attempts in girls only. Journal of Abnormal Child Psychology 42(3): 467–477.

42.

King

Katz

Ghaziuddin

. (1997) Diagnosis and assessment of depression and suicidality using de NIMH Diagnosis Interview Schedule for Children (DISC 2.3). Journal of Abnormal Child Psychology 29: 173–181.

43.

Knafo

Guile

Breton

. (2015) Coping strategies associated with suicidal. Canadian Journal of Psychiatry 60(2 Suppl 1): S46–S54.

44.

Koutek

Kocourkova

Dudova

(2016) Suicidal behavior and self-harm in girls with eating disorders. Neuropsychiatric Disease and Treatment 12: 787–793.

45.

Labelle

Breton

Berthiaume

. (2015) Psychometric properties of three measures of protective factors for depression and suicidal behaviour among adolescents. Canadian Journal of Psychiatry 60(2 suppl 1): S16–S26.

46.

Larzelere

Andersen

Ringle

. (2004) The Child Suicide Risk Assessment: a screening measure of suicide risk in pre-adolescents. Death Studies 28(9): 809–827.

47.

Larzelere

Smith

Batenhorst

. (1996) Predictive validity of the Suicide Probability Scale among adolescents in group home treatment. Journal of the American Academy of Child & Adolescent Psychiatry 35(2): 166–172.

48.

Lee

(2011) Reasons for living and their moderating effects on Korean adolescents’ suicidal ideation. Death Studies 35(8): 711–728.

49.

Levac

Colquhoun

O’Brien

(2010) Scoping studies: advancing the methodology. Implementation Science 5(1):69.

50.

Lewis

Roberts

(2001) Crisis assessment tools: the good, the bad, and the available. Brief Treatment and Crisis Intervention 1: 17–28.

51.

Mazza

(2000) The relationship between posttraumatic stress symptomatology and suicidal behavior in school-based adolescents. Suicide & Life-threatening Behavior 30(2): 91–103.

52.

Mazza

Reynolds

(1999) Exposure to violence in young inner-city adolescents: relationships with suicidal ideation, depression, and PTSD symptomatology. Journal of Abnormal Child Psychology 27(3): 203–213.

53.

Mcnicholas

(2011) Poster abstracts from the AAAP 21st annual meeting and symposium. American Journal on Addictions 20(4): 391–392.

54.

Merikangas

Nakamura

Kessler

(2009) Epidemiology of mental disorders in children and adolescents. Dialogues in Clinical Neuroscience 11(1): 7–20.

55.

Mieczkowski

Sweeney

Haas

. (1993) Factor composition of the suicide intent scale. Suicide and Life-Threatening Behavior 23(1): 37–45.

56.

Miller

Norman

Bishop

. (1986) The modified scale for suicidal ideation: reliability and validity. Journal of Consulting and Clinical Psychology 54(5): 724–725.

57.

Mind (2013) What is a mental health crisis? Mental Health Crises. Available at: https://www.mind.org.uk/information-support/guides-to-support-and-services/crisis-services/#.WUj6-a-Wzcs (accessed 25 May 2017).

58.

Miranda

Ortin

Scott

. (2014) Characteristics of suicidal ideation that predict the transition to future suicide attempts in adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines 55(11): 1288–1296.

59.

Mirkovic

Labelle

Guilé

. (2015) Coping skills among adolescent suicide attempters: results of a multisite study. Canadian Journal of Psychiatry 60(2): S37–S45.

60.

Morano

Cisler

Lemerond

(1993) Risk factors for adolescent suicidal behavior: loss, insufficient familial support, and hopelessness. Adolescence 28(112): 851.

61.

National Institute for Health and Clinical Excellence (2004) The Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care. London: Royal College of Psychiatrists.

62.

National Institute for Health and Clinical Excellence (2013) Self Harm: Quality Standard 34. London: National Institute for Health and Clinical Excellence.

63.

Ofek

Weizman

Apter

(1998) The child suicide potential scale: inter-rater reliability and validity in Israeli in-patient adolescents. Israel Journal of Psychiatry and Related Sciences 35(4): 253–261.

64.

Office of National Statistics (ONS) (2016). Suicides in the UK: 2016 Registrations. London: HMSO. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2016registrations (accessed 26 May 2017).

65.

Olfson

Gameroff

Marcus

. (2005) Emergency treatment of young people following deliberate self-harm. Archives of General Psychiatry 62(10): 1122.

66.

Orbach

Feshbach

Carlson

. (1984) Attitudes toward life and death in suicidal, normal, and chronically ill children: an extended replication. Journal of Consulting and Clinical Psychology 52(6): 1020–1027.

67.

Orbach

Milstein

Har-Even

. (1991) A Multi-Attitude Suicide Tendency scale for adolescents. Psychological Assessment, American Psychological Association 3(3): 398–404.

68.

Osman

Barrios

Grittmann

. (1993) The Multi-Attitude Suicide Tendency scale: psychometric characteristics in an American sample. Journal of Clinical Psychology 49(5): 701–708.

69.

Osman

Barrios

Panak

. (1994) Validation of the Multi-Attitude Suicide Tendency scale in adolescent samples. Journal of Clinical Psychology 50(6): 847–855.

70.

Osman

Gilpin

Panak

. (2000) The Multi-Attitude Suicide Tendency scale: further validation with adolescent psychiatric inpatients. Suicide & Life-threatening Behavior 30(4): 377–385.

71.

Osman

Kopper

Linehan

(1998) The Reasons for Living Inventory for Adolescents (RFL-A): development and psychometric properties. Journal of Clinical Psychology 54(8): 1063–1078.

72.

Parsonage

Fossey

Tutty

(2012) Liaison psychiatry in the modern NHS. Available at: http://www.centreformentalhealth.org.uk/publications/liaison_psychiatry.aspx?ID=665 (accessed 26 May 2017).

73.

Pettit

Garza

Grover

. (2009) Factor structure and psychometric properties of the modified scale for suicidal ideation among suicidal youth. Depression and Anxiety 26(8): 769–774.

74.

Pfeffer

(1986) The suicidal child. New York: Guilford Press.

75.

Pfeffer

Jiang

Kakuma

(2000) Child–Adolescent Suicidal Potential Index (CASPI): a screen for risk for early onset suicidal behavior. Psychological Assessment 12(3): 304–318.

76.

Plutchik

Van Praag

Conte

. (1989) Correlates of suicide and violence risk: I. The suicide risk measure. Comprehensive Psychiatry 30(4): 296–302.

77.

Posner

Brown

Stanley

(2011) Columbia-suicide severity rating scale: initial validity and internal consistency finding from three multisite studies with adolescents and adults. American Journal of Psychiatry 168(12): 1266–1277.

78.

Quinlivan

Cooper

Meehan

. (2017) Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study. British Journal of Psychiatry 210(6): 429–436.

79.

Range

Lewis

(1992) Life orientation inventory: a method of assessing suicide risk. Journal of Psychoeducational Assessment 10(3): 296–297.

80.

Reynolds

Mazza

(2001) Assessment of suicidal ideation in inner-city children and young adolescents: reliability and validity of the suicidal ideation questionnaire-JR. School Psychology Review 30: 376–384.

81.

Reynolds

(1987a) Suicidal Ideation Questionnaire-Junior. Psychological Assessment Resources. Odessa: Psychological Assessment Resources.

82.

Reynolds

(1987b) Suicide Ideation Questionnaire. Odessa: Psychological Assessment Resources.

83.

Reynolds

(1990) Development of a semistructured clinical interview for suicidal behaviors in adolescents. Psychological Assessment 2(4): 382–390

84.

Reynolds

(1990) Suicide Behaviors Interview. Odessa: Psychological Assessment Resources.

85.

Rhodes

Bethell

Carlisle

. (2014) Time trends in suicide-related behaviours in girls and boys. Canadian Journal of Psychiatry 59(3): 152–159.

86.

Rodway

Tham

Ibrahim

. (2016) Suicide in children and young people in England: a consecutive case series. Lancet Psychiatry. 3(8): 751–759.

87.

Romanowicz

MO’

Connor

Schak

. (2013) Use of the Suicide Status Form-II to investigate correlates of suicide risk factors in psychiatrically hospitalized children and adolescents. Journal of Affective Disorders 151(2): 467–473.

88.

Rosenberg

Robert

Thomas

. (2006) Assessing potential suicide risk at young adults burned as children. Journal of Burn Care & Research 27(6): 779–785.

89.

Schmidtke

Bille-Brahe

DeLeo

. (1996) Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992. Results of the WHO/EURO multicentre study on parasuicide. Acta Psychiatrica Scandinavica 93: 327–338.

90.

Schulz

Altman

Moher

(2010) CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Annals of Internal Medicine 152(1): 18.

91.

Schwartz-Stav

Apter

Zalsman

(2006) Depression, suicidal behavior and insight in adolescents with schizophrenia. European Child and Adolescent Psychiatry 15(6): 352–359.

92.

Shaffer

Scott

Wilcox

. (2004) The Columbia SuicideScreen: validity and reliability of a screen for youth suicide and depression. Journal of the American Academy of Child & Adolescent Psychiatry 43(1): 71–79.

93.

Shaunesey

Cohen

Plummer

. (1993) Suicidality in hospitalized adolescents: relationship to prior abuse. American Journal of Orthopsychiatry 63(1): 113–119.

94.

Spirito

Stark

Fristad

(1987) Adolescent suicide attempters hospitalized on a pediatric unit. Journal of Pediatric Psychology 12(2): 171–189.

95.

Spirito

Sterling

Donaldson

. (1996) Factor analysis of the suicide intent scale with adolescent suicide attempters. Journal of Personality Assessment 67(1): 90–101.

96.

Stanley

Snyder

Westen

. (2013) Self-reported recent life stressors and risk of suicide in pediatric emergency department patients. Clinical Pediatric Emergency Medicine 14(1): 35–40.

97.

Stathis

Litchfield

Letters

. (2008) A comparative assessment of suicide risk for young people in youth detention. Archives of Suicide Research: Official Journal of the International Academy for Suicide Research 12(1): 62–66.

98.

Storch

Bussing

Jacob

. (2014) Frequency and correlates of suicidal ideation in pediatric obsessive–compulsive disorder. Child Psychiatry and Human Development 46(1): 75–83.

99.

Vatne

Finset

Ornes

. (2010) Application of the Verona Coding Definitions of Emotional Sequences (VR-CoDES) on a pediatric data set. Patient Education and Counseling 80(3): 399–404.

100.

Wong

(2004) Attitudes toward life and death among Chinese adolescents: the Chinese version of the Multi-Attitude Suicide Tendency scale. Death Studies 28(2): 91–110.

101.

Zhang

Yip

(2014) Validation of the Chinese version of the Reynolds’ suicidal ideation questionnaire: psychometric properties and its short version. Health and Quality of Life Outcomes 12(1): 33.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.25 MB

0.23 MB