One of the main concerns about asking preadolescents (8-12 year olds) about suicidal thoughts is the fear that it will actually cause or increase suicidal thoughts (i.e, have an iatrogenic effect). Because preadolescence is a time of rapid cognitive development, where young people may be more suggestible, it has been proposed that asking or talking to them about sensitive topics like suicide might cause distress and introduce ideas that they had not previously considered (Ayer et al., 2020). This makes people hesitant to ask preadolescents about suicidal thoughts, both in research and in practice.
However, one review found that around one in 13 children younger than 12 years old experience suicidal ideation (read more in a recent blog by Rasanat and Mahmoud). This introduces a clinical dilemma: avoiding the topic may feel protective but by failing to ask, you risk not offering support to children who are already struggling with suicidal thoughts.
Encouragingly, there is evidence to suggest early identification of suicidal thoughts and appropriate intervention can be effective in reducing risk in this age group (Colizzi et al., 2020). With this in mind, Hennefield and colleagues (2026) examined whether there are any iatrogenic effects of suicide screening in two groups of preadolescents; those with no reported history of suicidal thoughts (lower-risk) and those with a history of suicidal thoughts (higher-risk). Specifically, they aimed to find out if repeated screening was associated with new suicidal thoughts in the lower-risk group and an increase in suicidal thoughts for the higher-risk group.
Clinicians face a dilemma: avoiding asking preadolescents about suicidal thoughts may feel safer because it reduces the risk of causing distress, but not asking may mean missing the opportunity to provide support.
Methods
The study followed preadolescents from Missouri who had previously taken part in research evaluating psychotherapy for preschool-onset major depressive disorder (PO-MDD). At baseline, participants and their caregivers completed an in-person structured psychiatric interview to assess suicidal thoughts and were separated into two groups: lower-risk and higher-risk.
Over the next 12 months, participants completed an adapted online version of the Ask Suicide-Screening Questions (ASQ; Horowitz et al., 2012). Lower-risk participants completed it monthly, while higher-risk participants completed it weekly. The adapted tool included three items about the past week (wishing to be dead, feeling others would be better off if they were dead, and thoughts of killing themselves), with the authors adding a fourth item to assess current intent. Any “yes” response was counted as a positive screen.
Analyses used Pearson correlations and hierarchical generalised linear models, controlling for age and sex, to test whether repeated screening increased suicidal thoughts. Bayes factor analysis examined the meaningfulness of the null effect, and further sensitivity analyses were done on lower-risk participants to remove preadolescents with any history of PO-MDD, as PO-MDD strongly predicts suicidal thoughts in adolescents.
Results
Overall, 192 preadolescents agreed to take part and completed at least one ASQ survey. The mean age of participants was 10.13 years old (SD = 1.02) and 79.2% of the participants were White. In the lower-risk group (n = 68), 98.4% of the screens across the 12 months were negative and only 1.6% were positive. For the higher-risk group (n = 124) across the 12 months, 93% of screens were negative and 7% were positive.
Lower-risk group
Analyses found:
- No relationship between how many ASQ surveys were completed and how many were positive screens (r = 0.16, p = .192) meaning that there was no cumulative effect of completing the screening on increasing suicidal thoughts.
- No evidence that the survey week (i.e., how many times a preadolescent was asked about suicidal thoughts) predicted the chances of a positive screen (i.e., more reports of suicidal thoughts) (OR = 1.04, 95% CI [1.00 to 1.09], p = .067) even when controlling for sex at birth and within-subject age.
- No evidence that completing the survey in one month predicted the likelihood of a positive screen in the next month (OR = 0.40, 95% CI [0.07 to 2.19], p = .288), including when sex at birth and within-subject age was controlled for.
A Bayes factor analysis supported the null findings, and results from the sensitivity analysis were similar to the primary analysis, reinforcing that there is no evidence that repeat ASQ screening increases positive screenings for suicidal thoughts, even when removing the potential confounding factor of early depression history.
Higher-risk group
The findings were the same for the higher-risk preadolescent group who received the ASQ weekly:
- No significant association between survey completion rates and positive screenings (r = 0.11, p = .242).
- Survey week did not predict positive screens (OR = 0.99, 95% CI [0.98 to 1.00], p = .160)
- No relationship between completing the survey one week and the chances of a positive screen the following week (OR = 0.93, 95% CI [0.59 to 1.47], p =.756).
These results were also supported by the Bayes factor analysis confirming that there was no harmful effect of repeated ASQ screening in this group of preadolescents.
Repeated suicide screening was not associated with iatrogenic effects in preadolescents with and without a history of suicidal thoughts.
Conclusion
Overall, this study found initial evidence to suggest that repeated suicide screening is not associated with an increased likelihood of suicidal thoughts in preadolescents with and without a history of suicidal thoughts. There was no evidence to suggest that the more screenings preadolescents completed, the higher the likelihood of them having a positive screen, nor that completing a screening one week/month increased the likelihood of a positive screen the next week/month. The authors concluded that, while there are justifiable concerns about asking preadolescents about suicidal thoughts:
Findings suggest that funders, investigators, parents, and youth can feel more confident about youth participating and contributing to this critically needed research. Findings also suggest that clinicians can proceed with screening in children in this age group with confidence that the benefits outweigh the risks.
Findings from this study suggest that it is relatively safe to ask preadolescents about suicidal thoughts in the context of mental health research, which may transfer to clinical settings.
Strengths and limitations
Strengths
- The combination of different statistical tests used by the authors (i.e., hierarchical models, Bayes factors) strengthens the interpretation of the study findings, increasing our confidence that there is no impact of repeated ASQ screening on suicidal thoughts in this population.
- The authors used a longitudinal design to follow preadolescents across a 12-month period. This is important because suicidal thoughts can fluctuate, meaning a single measurement may have misrepresented actual risk; as such, this increases the reliability of the findings.
- Results were based on data from the ASQ, which is a validated tool with strong psychometric properties. This increases our confidence that the study actually measured suicidal thoughts, and that this was done in a consistent and reliable way.
- The completion rates for the ASQ screenings were high (~75-75%) meaning that the data is likely to be reliable and representative for this sample. This also indicates that regular suicide-risk screening is feasible and acceptable for preadolescents.
Limitations
- Most of the sample were White, which limits the generalisability of the findings to other more diverse groups. This is particularly important, as evidence suggests there is a higher suicide risk and rate among minority ethnic youth compared with White youth (Alvarez et al., 2022), which may be relevant to suicide-risk screening.
- Similarly, some of the cohort used in this study had previously undergone psychotherapy for PO-MDD. While sensitivity analyses addressed the confounding factor of PO-MDD history, it is unclear what impact the intervention and previous exposure to the topic of suicidal thoughts may have had.
- Relatedly, many potentially confounding factors were not included in the analysis which may have had an impact, such a life events (e.g., loss of a loved one, parent divorce).
- While the current intent item that was added to the ASQ was important for the study’s purpose, it is unclear whether this adaptation may have affected the questionnaire’s validity, thus making the findings untrustworthy.
While the use of a validated measure of suicide risk is a strength of the study, it is unclear what impact the authors’ adaptations had on its psychometric properties and overall reliability.
Implications for practice
Findings from this study seem to support that for this sample, repeatedly asking about suicidal thoughts across 12 months does not increase suicidal thoughts occurrence. Although these findings are preliminary, with the authors emphasising that they “want to be careful about claiming no risk for youth when engaging in suicide-risk screening”, it could help to alleviate concerns around asking preadolescents about suicidal thoughts. Not only might this make it more feasible for researchers to conduct important research related to suicidal thoughts and behaviours, but it also may help clinicians to feel more confident in proactively asking about suicidal thoughts. This could result in earlier identification of suicidal thoughts and more wrap-around care for those in need, which could be crucial in reducing suicide risk for this population. Parents and carers can also be reassured that there is limited risk in preadolescents taking part in this type of research or potentially being asked these questions by clinicians.
However, some caution is still needed due to the lack of clarity whether these findings would be applicable across different populations and settings. Future research should include preadolescents from different racial and ethnic backgrounds, as well at those who have never received any mental health support. Additionally, the ASQ asks about suicidal thoughts over the past week; future research could consider using methods such as ecological momentary assessment (EMA) to capture suicidal thoughts in real time and see if there are any iatrogenic effects in this format, as there could be difference.
There is also a wider conversation to be had around how clinicians should screen for suicidal thoughts. Young people have expressed negative views about having their suicidal risk being assessed using risk assessment tools as they find these inflexible and non-holistic, with the potential to invalidate someone’s feelings if the outcome doesn’t match their experience (Bellairs-Walsh et al., 2020). Clinicians have also expressed fears that using risk assessment tools may result in inappropriate or missed referrals and impact their rapport with patients due to the questions on assessments sometimes being blunt and insensitively phrased (Michail et al., 2015). Further qualitative research could be used to explore preadolescents’ perceptions and views of being repeatedly administered the ASQ screener, which could provide further insight into the current study’s findings.
Future studies could extend this research to see if more frequent screening, such as daily diaries or ecological momentary assessment, is similarly safe in this population.
Statement of interests
Kayley McPherson has no conflict of interest to disclose.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Laura Hennefield, Katherine R. Luking, Rebecca Tillman, Deanna M. Barch, Joan L. Luby, & Renee J. Thompson (2026). Asking preadolescents about suicide is not associated with increased suicidal thoughts. Journal of the American Academy of Child & Adolescent Psychiatry, 65(1), 34–41. https://doi.org/10.1016/j.jaac.2025.03.025
Other references
Alvarez, K., Polanco-Roman, L., Samuel Breslow, A., & Molock, S. (2022). Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. American Journal of Psychiatry, 179(6), 422-433. https://doi.org/10.1176/appi.ajp.21101001
Ayer, L., Colpe, L., Pearson, J., Rooney, M., & Murphy, E. (2020). Advancing research in child suicide: A call to action. Journal of the American Academy of Child & Adolescent Psychiatry, 59(9), 1028-1035. https://doi.org/10.1016/j.jaac.2020.02.010
Bellairs-Walsh, I., Perry, Y., Krysinska, K., Byrne, S. J., Boland, A., Michail, M., … & Robinson, J. (2020). Best practice when working with suicidal behaviour and self-harm in primary care: A qualitative exploration of young people’s perspectives. BMJ Open, 10(10), e038855. https://doi.org/10.1136/bmjopen-2020-038855
Colizzi, M., Lasalvia, A., & Ruggeri, M. (2020). Prevention and early intervention in youth mental health: Is it time for a multidisciplinary and trans-diagnostic model for care? International Journal of Mental Health Systems, 14(1), 23. https://doi.org/10.1186/s13033-020-00356-9
Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., … & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of Pediatrics & Adolescent Medicine, 166(12), 1170-1176. https://doi.org/10.1001/archpediatrics.2012.1276
Michail, M., & Tait, L. (2016). Exploring general practitioners’ views and experiences on suicide risk assessment and management of young people in primary care: A qualitative study in the UK. BMJ Open, 6, e009654. https://doi.org/10.1136/bmjopen-2015-009654
Nawaz, R. F., & Arif, M. (2023). Suicide and self-harm in children: prevalence rates cause for concern. The Mental Elf.
