Stepped-Care for Suicidal Youth and Children

This primary outcome measure assesses the change in the severity of suicidal thoughts and behaviors (STB) among participants over time, relative to their initial state at baseline. Data for this measure will be collected using the Columbia-Suicide Severity Rating Scale (C-SSRS).

The C-SSRS is a standardized, clinician-administered tool that consists of a series of questions designed to identify, classify, and quantify the severity of a person's suicidal thoughts and behaviors. The scale addresses five types of suicidal ideation (e.g., thoughts of suicide without a plan or intent) and six types of suicidal behaviors (e.g., actual suicide attempts).

The assessment is conducted at multiple time points. The change in C-SSRS scores between these time points will be used to compare the intervention group with the control group, determining whether the new treatment is more effective in reducing suicidal risk in children and adolescents.

This measure evaluates the feasibility and fidelity of implementing the Stratified-Stepped-Care (SSC) model into the existing clinic workflow.

Feasibility will be measured by calculating the percentage of adherence to the study protocol for both providers and participants (e.g., percentage of sessions completed, percentage of core protocol elements delivered). Fidelity will also be assessed via direct observation and completion of a standardized Protocol Adherence Checklist. Higher percentages indicate greater feasibility and fidelity to the SSC model and a better outcome.

This outcome measure assesses the change in depression levels among participants over time, relative to their initial state at baseline. Depression is measured using a standardized self-report questionnaire called the Mood and Feelings Questionnaire (MFQ).

The MFQ is a standard tool for measuring the severity of depressive symptoms in children and adolescents. Participants are asked to rate the frequency of various depressive symptoms (such as feeling sad, hopeless, or losing interest in activities) on a rating scale. A higher score on the questionnaire indicates greater depression severity. The assessment is conducted at multiple time pointsץ

Costs in US Dollars will include direct service costs (e.g., provider salaries, training, supervision, facility costs) and indirect costs (e.g., costs associated with hospitalizations or emergency room visits related to STB). These components will be aggregated to provide a single value for the total cost of care for the study period.

Lower total costs indicate greater economic efficiency and a better outcome.

The waiting time will be measured as the number of days from a participant's initial intake at the clinic to their first therapeutic session. This data will be collected for both the SSC group and the Care as Usual (CAU) group and will be compared to demonstrate whether the new model improves access.

From Initial Intake (Day 1) through the start of the first therapeutic session for each participant.

A lower number of days indicates reduced waiting time and a better outcome for access to care.

his outcome measure assesses the change in anxiety levels among participants over time, relative to their initial state at baseline. Anxiety is measured using a standardized self-report questionnaire called the Screen for Child Anxiety Related Emotional Disorders (SCARED).

The SCARED is a standardized questionnaire that screens for five main types of anxiety disorders: panic disorder, generalized anxiety disorder, separation anxiety disorder, social anxiety, and school avoidance. Participants are asked to rate how true specific symptoms have been for them in the last three months, using a rating scale. A higher score on the questionnaire indicates greater anxiety severity.

This measure assesses change across four domains: individual/personal functioning, interpersonal relationships, social role performance (e.g., school/work), and overall well-being.

The Outcome Rating Scale (ORS) is for adolescents and their parents, and the Child Outcome Rating Scale (CORS) is for children ages 6-12 and their parents. Scores range from 0 to 40. (The scale consists of 4 items, scored from 0-10 each).

Higher scores indicate better overall functioning, well-being, and progress in treatment.

Satisfaction will be measured using a dedicated staff survey assessing the perceived ease of the training process, comfort level with the protocol, and perceived integration into clinic workflow.

. Scores range from 1 to 5 (or the specific range of the Likert-type scale used).

Higher scores indicate greater satisfaction with the training, supervision, and integration of the SSC model, reflecting a better outcome for implementation.

The questionnaire comprises five scales, each scored from 0 to 10: four difficulties scales (Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention, and Peer Problems), and one Prosocial Strengths scale. The scores from the four difficulties scales are summed to create a Total Difficulties Score, ranging from 0 to 40. Higher scores on the four difficulties scales and the Total Difficulties Score indicate greater problems and a worse outcome. Conversely, higher scores on the Prosocial Strengths scale indicate greater positive behaviors and a better outcome.

This measure evaluates the change in the presence and severity of post-traumatic stress symptoms in participants using the Child Posttraumatic Stress Disorder Symptom Scale (CPSS). The CPSS is a reliable and well-known tool adapted for children and adolescents and is based on the DSM-5 diagnostic criteria for Post-Traumatic Stress Disorder (PTSD). Used to assess the presence and severity of symptoms consistent with the DSM-5 diagnostic clusters of PTSD.

The questionnaire checks for the presence and severity of symptoms across four main clusters: Re-experiencing, Avoidance, Negative Alterations in Cognitions and Mood, and Hyperarousal. Scores range from 0 to 51. (27 items scored 0-4, with some items combined to yield a total score).

Higher scores indicate greater severity of post-traumatic stress symptoms and a worse outcome.

This questionnaire assesses the current or recent experience of emotion regulation challenges across six key domains.

Measures the presence and severity of emotion regulation difficulties in six Subscales Assessed 1. Non-acceptance of emotional responses: Rejects current emotional experiences.

• Difficulty engaging in goal-directed behavior: Difficulty concentrating or completing tasks when distressed.

• Lack of emotional awareness: Not paying attention to or understanding one's emotional state.

• Impulse control difficulties: Acting rashly or destructively when distressed.

• Lack of emotional clarity: Difficulty defining or distinguishing between different emotions.

• Limited access to emotion regulation strategies: Perceiving one's ability to cope as restricted.

Scores typically range from 36 to 180 (based on the original 36-item full scale, with each item scored 1-5).

Higher scores indicate greater difficulties in emotion regulation and a worse outcome.

This measure evaluates the frequency, types, and motives of Non-Suicidal Self-Injury (NSSI) using the Deliberate Attempt to Self-Harm Inventory (DASH-I). The DASH-I assesses various aspects of NSSI, including the types of behaviors (e.g., cutting, burning, hitting), their frequency, and the context and motives (e.g., to reduce emotional pain, punish oneself) behind the behaviors. Minimum Score: 0 (No NSSI episodes in the defined timeframe). Maximum Score: Varies, depending on the highest frequency category chosen (e.g., 50+).

Higher scores on the frequency scales indicate more frequent self-harming behavior and a worse outcome.

Since the DASH-I is an inventory, not a single psychometric scale, its maximum possible score is highly variable and often depends on the specific time frame assessed (e.g., past year).

The Children's Global Assessment Scale (CGAS) used by the clinician to assess the participant's overall level of functioning and adaptation in daily life. Scores range from 1 to 100. Higher scores indicate better overall functioning. (100 = Superior functioning; 1 = Needs continuous supervision).

The Clinical Global Improvement (CGI) - Used by the clinician to assess the participant's severity of illness and improvement (or worsening) in symptoms over time. Scores range from 1 to 7. Lower scores indicate better/more significant improvement. (1 = Very much improved; 7 = Very much worse).

This measure evaluates the acceptability and satisfaction of the SSC model from the perspective of the participants (children/adolescents and their parents). Scores range from 4 to 16 (4 items, scored 1-4 each).Higher scores indicate greater satisfaction with the intervention and a better outcome.

Satisfaction levels of participants and their parents will be measured using the CSQ-4. The scores will be supplemented by qualitative data from brief verbal interviews (not scored as part of this specific outcome).