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'''''' "s 
DEPARTMENT OF HEALTH &. HUMAN SERVICES  Office of Inspector General 
Memorandum 
4''',IIQ 
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Date

/sl. 
Bryan B. Mit()r: 
From
 Richard P. Kusserow 
Inspector General

Subject  OIG Final Report:  Assessment and Documentation of Youth at 
P-09-86-00l0l 
Risk of Suicide 
Jean K. Elder, Ph.

Acting Assistant Secretary

for Human Development Services

Attached for your information is our final inspection report 
enti tled "Assessment and Documentation of Youth at Risk of 
Suicide. " This .is the third in a series of three reports 
reflecting the findings of a national program inspection on 
youth suicide conducted at the request of the Secretary 
Task Force on Youth Suicide. The other two reports, entitled 
Youth Suicide " and  Inventory of State Ini tiati ves In 
Addressing Youth Suicide, " have been sent previously under 
separate memorandum. 
are: 
Our major findings 
Few respondents use formal tools to screen for risk of
suicide. Al 
though many respondents were very receptive to 
the idea that HHS develop a screening tool, some were 
skeptical that the Department could develop an effective
tool. 
A screening tool would be most useful to service providers 
who do not have a specific mental health focus or do not 
routinely work with clients at risk of suicide. Training 
essential. 
in the use of such a tool is 
Wi th the exception of hotlines and a few school districts

service providers do not maintain statistics on youth

suicide. 
Information on individual clients can usually be shared

wi th a signed release. Sharing of aggregate data is

generally not a problem.

If you have any questions, please have your staff contact

Ta Zitans at 472-5340.

Attachment 
cc:  Dodie Livingston 
Administration for Children, Youth

and Families
 ASSESSMENT AND DOCUMENTATION

OF YOUTH AT RISK OF SUICIDE

INTRODUCTION 
The Office of Inspector General 
(OIG) was asked to conduct a

quali ta ti ve 
national program inspection of youth suicide 
which would supplement the work of the Department of Health

and Human Services (DHHS) Task Force on Youth Suicide. 
The
primary focus of the inspection was to 
(a) assess the extent

to which BHS-funded programs are involved in efforts to

prevent youth suicide, (b) review how states and selected

communi ties are responding to the problems associated wi 

youth suicide and (c) identify barriers and gaps which

hinder delivery of services to suicidal youth and/or their

families. The results of this inspection are reflected in

Youth Suicide 
tIwno rie potrtisa, etntii  tvIed es in Addressing Youth Suicaindd e  Inventory of State
In addi tion, this special report has been prepared for Mark
Rosenberg, M. D., Chief of the Violence Epidemiology Branch, 
Centers for Disease Control (CDC). During his review of the
original inspection design, Dr. Rosenberg indicated that 
querying respondents on three issues would be helpful in his
work at CDC. 
Thus, the OIG inspection team asked 
respondents the following three questions: 
la. If HHS developed a screening tool to identify youth at

risk of committing suicide, would it be helpful to you?

(Explain yes or no.

b. If yes, would you actually use it?  (Explain) 
What kinds of records or documentation do you maintain

(e.g., clinical/client
on youth at risk of suicide 
records i aggregate statistics/analysis)? 
Do you share this information with any other agencies or

practi tioners? 
Why or why not? 
eflects responses to these questions. 
This report 
 Our 
findings are based on 348 interviews. Of this total, 170
in-
person interviews were conducted through visits to 10 
communi ties in 9 states. In a telephone survey of randomly 
selected communi ty service agencies (most of whom were
funded by HHS), OIG staff interviewed an addi 
persons. In all,  tional 178
we talked to persons in 183 communi ties 
throughout all 50 states.
 MAOR FINDINGS 
Almost all mental health professionals and many other 
service providers report that they look for indications 
of suicide risk. Their approach is often informal and 
subjecti ve, however, wi th reliance on clinical 
experience and judgment to detect warning signs. A few 
suicide. 
use formal tools to screen for risk of 
Al though 42% of the respondents report that they would 
use a screening tool developed by the Department and 
another 42% report they might use such a tool, several 
respondents are skeptitcoaol lt.h at the Department could 
develop an effective  BHS grantees do not want the 
tool. 
Department to require mandatory use of a screening 
A screening tool is seen as being of greatest value to 
service providers who work with youth,s ubiucti ddoe .n ot 
Mental 
routinely encounter youth at risk of 
heal th professionals and staff working wi th hotlines and 
crisis intervention programs express less interest in 
using a tool to screen individual clients, but perceive 
its utility to help with training and communi
education. 
School officials are skeptical that they 
would be allowed to use a screening tool due to policies 
on privacy and requirements for parental permission. 
It is important that anyone using a screeningi tt, ool

recei ve adequate training on (a) how to use 
(b) appropriate demeanor, attitudes and interviewing

approaches and (c) what to do if risk of suicide is

detected. 
Wi th the exception of hotlines, service providers do not 
suicides. 
keep statistics related to 
selectively, 
Most agencies share information on clients 
forms. Many' have 
as long as clients have signed release 
policies allowing them to share information without a 
release if the client is judged to be at risk of harming
r others. 
Release forms are not an issue when 
hsimhself aring aggregate data. CURRENT USE OF SCREENING TOOLS

Almost all mental health professionals and many other

service providers interviewed during this study report

that they look for indications of suicide risk among

their clients. Their 
screening approach is often

informal and subjective with a heavy reliance on 
clinical experience and judgment to detect warning
signs. 
Respondents also rely on patient self-reporting 
during the intake process, as well as routine mental

heal th status examinations and structured interviews.
few use formal tools to screen for risk of suicide.
Some respondents have developed their own tools for use 
wi thin their agencies. 
The OIG inspection team did not systematically inventory 
ours eev.a luate the various screening tools currently in
However, the following tools were identified by 
some respondents:

Aaron Beck Depression Inventory 
(mentioned most

frequently) 
Taylor Johnson Temperament Scale

Zung Test

Screen developed by Dan Leterri, currently at the
National Insti tute 
on Alcohol Abuse and Alcoholism 
Screen developed by Tom Barrett, psychologist
involved wi 
th the Suicide Prevention Allied 
Regional Effort (SPARE) and Cherry Creek School
District in Colorado

Screen developed by Elinor Bar, Suicide Prevention

Center, Pueblo, Colorado

Screen used by the Los Angeles Suicide Prevention

Cen ter

Screen developed by Mary Jane Rotheram
versi ty  , Columbia 
Uni 
OHDS has funded grantees to work wi 
th runaway and
homeless youth programs to identify and prevent youth 
tting suicide. 
from commi  Different approaches are being
tried, including the development of screening tools.
Several runaway programs in New York City are currently 
screening all clients for risk of 
suicide, using the
screen developed by Dr. Rotheram, listed above. 
This
tool, designed for paraprofessionals and service agency 
th Ii ttle 
staff wi  or no mental health background,
identifies risk, assesses the immediacy of the problem
 and helps workers begin to structure an intervention
strategy. 
Staff using the screen participate in a short 
formal training program wi th a follow-up session after
they have screened a few clients. 
Participating runaway
programs are universally supportive of ,
this initiative.  II. INTEREST IN BHS DEVELOPMENT OF A SCREENING TOOL

Reaction was generally positive to a possible BHS

ini tiative to develop a screening tool which would
identify youth at risk of suicide. Forty-two percent of
the respondents who answered the question indicated they 
would welcome and use such a 
tool, while an additional
42% said they might find such a tool useful under 
certain circumstances. By 
far, the most enthusiastic

response came from service providers without a specific 
mental health or suicide prevention 
focus. As the
following table indicates, the highest interest in 
acquiring a new screening tool was among 
(I) communi ty
service providers such as runaway progrars, juvenile 
justice agencies and multi-service youth agencies and 
(2) health providers such as communi 
ty and migrant
heal th centers, family planning programs and adolescent 
health clinics. .We would welcome anything that would
help us, 
. was a common response. 
INTEREST IN A NEW SCREENING TOOL

Res  onden ts 
Communi ty Agencies 
Providers  62%  31%

Heal th 
54%  34%  13%

Hotlines/Crisis Programs 
Mental Health Providers  25%  40%  35%

School s  23%  57%  19%
15%  46%  38% 
All Respondents 
268  42%  42%  16% 
As the above table indicates, respondents who are more

routinely confronted wi th suicidal youth (mental health

professionals, crisis interv 
ntion programs and hotlines)

tool. 
were less interested in a new screening 
Most
indicated they are comfortable wi 
th their current methods

and procedures of identifying high risk youth. 
Many
emphasized that a tool woulJ never take the place of

clinical intuition and judgment. Typical were the
comments of two mental health professionals:

We always welcome something 
would help too much.  new, but I don' t think it
If you' ve been in this field 
awhile, you sense when there'
s a problem.
 I might use  noL going to give me
the whole ansit,w knoewinrg .i t  is 
I wouldn' t use it in lieu of my 
clinical knowledge, but as a supp ement. 
Several mental health and crisis intervention 
professionals who expressed an interest in a screening 
tool indicated it would be useful in their efforts to 
educa te and train people in their communi ties, as opposed
to its utility in clinical diagnostic work with
clients. 
indi vidual 
Some typical comments: 
It would have value in elevating an awareness among

nonprofessionals--the lay public. Clinicians are

very familiar with the classic signs, but there is a

defini te need in the schools and in the community at

large. 
I can rely on my gut feeling because I've been in 
the business for 18 years, but to train others I need 
a too 
1 . "

It would be good for front line service providers.

Once we can get kids into a clinical setting, we

comfortable we can sense suicide as a problem, but so

many suicidal kids never get that far.

School off  tool. 
icials also expressed less interest in a 
Many emphasized that school policies preclude staff from 
administering any type of individual assessment or survey
wi thout 
administrative or school board approval or 
parental permission. Noted one official, -Schools have 
strict laws on privacy and questionnaires. I would have 
a concern about objections from parents.  School 
officials also questioned whether they would have time to 
administer a screening tool, given heavy workload
demands. 
Despi te general support for the concept of developing a 
screening tool, there was considerable ambivalence and 
some skepticism that the Department could produce a tool 
that would be a better predictor than is already
available. 
Several respondents indicated they would want 
to evaluate any tool HHS might develop and compare it 
wi th their own screens before judging its utility. Some 
typical comments: 
Lots of people are trying to develop an effective

screen that works with kids, but so far nobody' s been

able to come up wi th one.

I can' t imagine you could come up wi th something we
t already know. It' 
don  s the subtleties that drive 
us crazy. 
Suicide is a very difficult outcome to
predict. .  . "
Other respondents questioned the value of using screens 
to predict youth at risk of suicide, noting in particular 
that screens which have worked well with adults have had 
teens. 
less utility when applied to 
Respondents stressed
tha t the effectiveness of screens is dependent upon 
accurate self-reporting, frequently a problem among
adolescents. 
Some mental health practi tioners noted that 
thei r ini tial impressions often change after they have 
had a few sessions with a client and that a screen only

measures a client' s behavior and atti 
time. - tude at a given

These are volatile kids and circumstances can

change quickly, 
" noted one researcher. 
There were some

suggestions that BHS should put resources into

identifying and evaluating existing tools, as opposed to

reinventing the wheel.

Respondents also stressed that no tool will identify all

high risk youth. "
We can add one more tool to the

arsenal, but , 
official.  ll never catch them all, - noted a school

Other typical comments included: 
Most tools don' t measure nonverbal cl ues. A screen 
would be useless if it told us that most or all the

kids have some risk factors. We already know that.

The challenge is figuring out who is going to go

ahead and do it.

Suicide is very hard to predict. 
I am concerned

tha t any tool HHS developed would be too general and

simplistic to be of much value. 
We could end up

registering lots of false positives, while others

would be missed. This could foster a false

complacence. 
tools. 
Beware of absolute  Experience has shown us
there 
s no clear-cut scale to really determine risk. 
When a person is in crisis, he doesn' t want someone
interrogating him. 
He becomes frightened and will
hang up. 
If HHS proceeds with the development of a screening tool,
respondents 
suggested that the following be considered: 
Training 
If you re going to use a tool, you can' 
just give it to people and expect it to 
work, - noted

one researcher. Several respondents stressed that it

is essential to train anyone screenin 
for problems

as sensi ti ve as suicide ri 
sk in (I) how to use the
screen, (2) appropriate demeanor, attitudes and 
approaches to asking questions in nonthreatening ways 
and (3) what to do if risk of suicide is detected. 
It is important that screeners address their own 
feelings about suicide, since this is an issue that  makes many people nervous and uncomfortable.

Furthermore, screens do not work well if users

believe there are no constructive treatment option

available. 
Noted one clinician, "
If someone doesn' 
know what to do or where to 
go, he won' t identify a

kid at risk. There is a tendency to deny the problem

if nothing can be done about it. 
. It was reported

that the benefits of using a tool often extend beyond

a diagnostic value by stimulating staff interest in

and demand for more training on issues related to

suicide. 
Training should be ongoing because users 
become complacent when they use the same tool

repeatedly. It was suggested that revising the

forma t occasionally helps resolve this dilema. 
Length and Complexity  Many respondents said they

would use a tool only if it were simple and did not

take too long to administer. 
Some said they would be
willing to incorporate a few questions into their

current intake forms. 
Content 
A tool should go beyond diagnosis of risk.
There should also be components which assess the
lethali ty and 
immediacy of risk, as well as helping 
the interviewer decide what to do when a high risk

youth is identified.

Vol untary Screening 
BHS grantees emphasi zed they
would oppose any mandatory requirement to screen

clients for risk of suicide. 
Noted one state 
official, "Please don' t tie dollars to it or restrict 
us by mandating your tool over something that might

better meet our needs. " A family planning grantee

said they would willingly use a screen -if we had the
I uxury of an 
optimal program, but not under the
reali ty of our current budget si 
tuation. " 
Cul tural Sensi ti vi ty  There was considerable concern

that a tool be sensitive to various ethnic and 
socioe 
onomic groups. Many respondents said they
would review any tool the Department developed to

determine whether it could be adapted to their

particular client groups.
 MAINTAINING RECORDS AND STATISTICS ON YOUTB SUICIDE

III. 
AND SHARING INFORMTION 
Almost all the service providers keep individual case

files on clients. This is true of virtually all the

heal th and mental health service providers and most of 
the runaway programs and other youth service agencies.
Any information related to risk of suicide is documented 
in the case file. Almost all the service providers 
report that they selectively share relevant information 
on a client with parents and other service providers, but
only if the client signs a release. Many indicated, 
however, that they make exceptions to this policy if a 
client is judged to be in imminent danger of harming 
himself or others, which would include risk of suicide. 
Obtaining a release from individual clients is not seen
as a problem. 
Often clients are informed of agency 
policies with regard to conf identiali ty when they begin
recei ving services. 
Many agencies report that they maintain statistics, but

do not systematically collect data with regard to suicide

ideation, gestures, attempts or completions. 
Some 
indicated they could manually tabulate this information, 
time. 
but the process would take considerable  Several
respondents said that they had the capabili 
ty to collect 
this type of information, but nobody has ever made such a
request. 
Sharing aggregate information is generally not 
a problem. 
The exceptions are the hotlines. Most hotlines keep a

record of each telephone call received and can report in

the aggregate the number of calls in which suicide was

the primary presenting problem. 
Most do not record the 
nature of the call by an age category, however, so it

would be difficult to determine how many calls were from

youth. 
Furthermore, the hotlines emphasize that their 
report of suicide calls is very conservative, because the

presenting problem is often something else and suicide is

an underlying issue.