5.21 Children at risk of suicide

This policy has been updated to reflect the changes to the Children’s Advice and Duty Services (CADS) that comes into effect from 17th October 2018.

This guidance has been produced for everyone who engages directly with children and young people in their day to day work and who may become aware of a young person’s suicidal thoughts or intentions. It is specifically aimed at professionals who have no training or expertise in the field of mental health and who do not have a role in the formal assessment of risk.

The purpose of this guidance is to ensure that the wider children’s workforce has an understanding of the process to be followed in Norfolk where concerns about possible risk of suicide exist. Everyone has a responsibility to identify young people at risk, including the risk of suicide, and to share information when action may be required to protect a child or young person. Professionals may also have a role in the implementation of a co-ordinated multi-agency Safety Plan or Risk Management Plan following completion of a detailed risk assessment by specialist mental health services or children’s social care.

There is a link between self-harm and suicide. Please refer to Appendix 2 for further information, and follow the NSCP guidelines.

We would like to thank the Worcestershire Safeguarding Board for allowing us to adapt their guidance.

1. Introduction

It is estimated that two young people take their own lives every day in the UK and that about 24,000 attempted suicides relate to children and young people aged 10 – 19 each year. Whilst females are more likely to attempt suicide, twice as many males die following suicide.
Nine young people under the age of 18 years died as a result of suicide/self-inflicted harm in Norfolk during the 10 year period 2005-15, significantly more than our statistical neighbours. Twice as many boys as girls have killed themselves, with hanging the most frequent cause of death. It is not possible to be specific about the numbers of attempted suicides due to difficulties in establishing whether a self-harm episode is an attempt at suicide or not. Self-harm is a common precursor to suicide and children and young people who self-harm may kill themselves by accident. Please see Appendix 2 and the NSCP guidance 5.21 for further information.

The Norfolk Suicide Review (2015) found that most of the young people who died were not known by specialist services such as CAMHS, social care, youth offending, etc. In most cases schools had concerns about young people, which they had raised with young person/parents. Schools had advised parents to take their child to see the G.P. Over half of young people were self-harming, and expressed suicidal thoughts to friends and on social networking sites. Two out of nine young people had experienced a significant family bereavement, some were experiencing sexual orientation/sexuality issues. There was little evidence of assessment of suicide risk, multi-agency risk assessments, implementing fully informed risk management strategies or safety planning.
The aims of this guidance are to:

Develop a shared language which supports effective information sharing
Standardise the response of agencies and practitioners to identifying and responding to young people who may be at risk of suicide by providing a referral pathway
Provide tools for practitioners to support the early identification of risk
Provide information about the respective roles of services and referral criteria

2. Principles and Values

Any child or young person, who expresses thoughts about suicide, must be taken seriously and appropriate help and intervention should be offered without delay.

It is acknowledged that suicide issues can be extremely challenging for practitioners, family members and communities
Assessments should be based on the unique experiences and feelings of each young person and not on the perceptions of adults
Young people should not be stigmatised or discriminated against because of suicidal thoughts or behaviour
It is acknowledged that belief systems can impact on individual attitudes towards suicide
A co-ordinated response by agencies is in the interests of young people at risk of suicide
Confidentiality and consent issues should not be barriers to effective joint working
Creating a safe and supportive environment should be a key aim
Conversations about suicide risk with young people should be held by those who know them best
Staff supporting young people should be offered appropriate advice and support by their organisation

3. Definitions

Suicidal behaviour is any deliberate action that has potentially life threatening consequences, such as taking an overdose. It can also include repeated risk taking which constitutes a risk of death.

Suicidal thoughts imply that someone is thinking about taking their own life. This differs from young people who, as part of normal growing up, might explore the meaning of life. Further conversations will usually establish whether someone is thinking about suicide.

Suicide is the act of deliberately ending one’s own life. It is possible to die unintentionally as a result of a serious self-harm episode.

Self-harm is the term used when someone intentionally injures or harms themselves. It is a common pre-cursor to suicide and children and young people who self-harm may kill themselves by accident.

Suicide prevention is the process of identifying and reducing the impact of risk factors associated with suicidal behaviour, and identifying and promoting factors that protect against engaging in suicidal behaviour.

4. Identifying risk factors

If a practitioner is concerned that a child or young person is at risk of suicide they should make a referral to the appropriate agency with responsibility for specialist mental health assessments. The process for doing so is set out in Section 5 of this guidance.

A risk assessment is only valid at the point that it is completed and needs to be updated in response to changing circumstances. Significant information can be obtained from the young person, but information will need to come from other sources, such as parents/carers, peers or professionals.

Risk factors give an indication of the potential for serious harm to occur, but cannot provide an accurate prediction of what will happen. Risk factors can be seen as ‘alarm bells’ – the more alarm bells that are ringing the greater the concern – however one significant risk factor can also trigger a young person having suicidal thoughts or behaviour.

Personal History

Previous self-harm, suicidal thoughts or suicide attempt
Substance use
Evidence of mental health problems, especially depression, psychosis, post-traumatic stress disorder or eating disorder
History of experiencing physical, emotional or sexual abuse
Loss or bereavement – could include loss of relationships or social status (anniversaries can be significant)
Pressure on social media
Family factors – instability (divorce, separation, changes of care giver, repeated house moves), conflict, arguments, domestic violence
Family history of suicide, mental illness or substance misuse
Issues of gender or sexual orientation
Children and young people who may have been radicalised
Bullying

Personal functioning

Changes in anxiety levels, problem solving skills, social withdrawal, feelings of hopelessness, personal appearance, sleeping and eating habits
Altered mental states, e.g. feelings of agitation, hearing voices, delusional thinking, aggression, intoxication
Statements of suicidal intent: letters, comments, Facebook status, social media messages, text messages, etc.
Tendency to impulsive behaviour
Running away from home
Anger, hostility or anti-social behaviour
Use or increased use of drugs/alcohol
Feelings of ambivalence about the future e.g. no reason for living, no purpose in life
Difficulty in coping with exam stress

Verbal warning signs

‘I can’t take it any more’
‘Nobody cares about me’
‘I can’t see the point any more’
‘Everyone would be better off if I weren’t here’
‘Nothing matters any more’
‘I’m going to top myself’

Levels of risk

High Risk	• Previous suicide attempts • Frequent suicidal thoughts which are not easily dismissed • Specific plans with access to potentially lethal means, e.g. time, location and method • Evidence of current mental health problems • Significant or increasing drug or alcohol use • Situation felt to be causing unbearable pain or distress • Increasing self-harm, either in frequency or potential lethality or both
Medium Risk	• Suicide thoughts are frequent but still fleeting • No specific plan or immediate intent • Known current mental health issue • Use/increased use of drugs or alcohol • Situation felt to be painful but no immediate crisis • Previous, especially recent, suicide attempt • Current self-harm or thoughts of self-harm
Standard Risk	• Suicidal thoughts are fleeting and soon dismissed • No plan of how they would attempt suicide • Fewer or no signs of low mood • No self-harming behaviour • Current situation felt to be painful but bearable

5. Referral pathway

‘There is no evidence that asking a young person whether they are having suicidal thoughts will put the thought in their mind if it were not there before. There is, however, a great deal of evidence to suggest that being able to talk to clients about suicide is extremely important in providing a safe space for them to explore their feelings.’
Rudd (2008), Barrio (2007)

If you have concerns that a young person has suicidal thoughts or behaviours you must follow the steps as laid out in this guidance.

Information Gathering conversation
Possible questions for an information gathering conversation are contained in Appendix 1. You will need to start the conversation by explaining the reasons for your concern, these questions aim to guide you through a conversation in which you can find out about suicide risk, which will inform your next actions. The conversation should be supportive and take account of the young person’s individual situation and his/her needs. Ideally, the conversation should be held by the worker who knows him/her best. Young people say that scaling questions might also be useful.

If the young person does not engage with the conversation, then follow advice in Section 7: young people who do not engage.

If there are no concerns about suicidal thoughts or behaviour and Standard Risk of suicide is indicated:

If the young person is standard risk in respect of suicide but has additional needs (not impacting on welfare) then consider a referral to the Early Help Hub or to other services (details Appendix 4) if appropriate.
If the young person is standard risk in respect of suicide but has other needs which impact on their safety or welfare, please consider contacting the Children’s Advice and Duty Service (CADS) (details Appendix 4).
If the young person is standard risk in respect of suicide but is showing early signs of mental health and emotional problems, please consider contacting the Children’s Advice and Duty Service (CADS) (details Appendix 4).
Give consideration to the impact on the young person’s support network

If your conversation indicate Medium or High Risk of suicide:

Explain limits of confidentiality and consent to share issues
Contact the Child and Adolescent Mental Health Service (CAMHS) for consultation and/or referral

You should also:

Liaise with parents/carers (where possible)
Inform Children’s Services if you think that the child may already be open to social care
Inform the young person’s GP
Contact CADS if the young person or parents/carers do not engage
Give consideration to the impact on the young person’s support network

Immediate Medical Attention

If suicidal actions have been disclosed or if the level of self-harm has resulted in a significant physical injury (e.g. recent overdose or serious cutting) it is important to ensure that the young person is assessed urgently in order to ascertain whether any immediate medical treatment is required. Take the young person to the Accident and Emergency department at the local hospital or consider dialling 999 and asking for an ambulance.
Inform the young person’s parents/carers.

If a young person tells you they are imminently about to take their own life

Do not leave the young person on their own.
If urgent assistance is required contact the emergency services.
Ring the CAMHS Access and Assessment team for an emergency assessment to be arranged (office hours and out of hours).

Safety Planning
You could also consider helping the young person to put together a safety plan.

6. Important things to remember

• Take suicide gestures seriously
• Listen, be non-judgemental and think about what you say
• Ask direct questions early on to establish the level of risk
• Ask about other problems such as bullying, substance misuse, bereavement, relationship difficulties, abuse, sexuality issues
• Check how and when parents/carers will be contacted
• Encourage contact with friends, family, trusted adults
• Ensure immediate support for the young person is in place and that medical attention is provided if necessary
• Consult with specialist services for advice
• Make sure you record your assessment, concerns and actions in line with your agency’s procedures
• Make appropriate referrals
• Engage with processes for developing Risk Management and Safety Plans
• Ensure actions to be taken by your agency to manage risk are implemented
• Consider protective factors and provide ongoing opportunities for support and monitoring
• Respond to escalating concerns about the risk of suicide

Do Not

• Promise confidentiality
• Make assumptions or react without considering all of the risks
• Dismiss what the young person is saying
• Presume that a young person who has threatened to harm themselves in the past will not do so in the future
• Disempower the young person
• Dismiss self-harm or expression of suicide thoughts as attention seeking

7. Young people who do not engage

If a child or young person is at risk of significant harm (S47 Children Act 1989) you have a duty to share concerns and information relevant to the risk. Some young people do not wish to engage with specialist services but may choose to engage with other professionals. If a young person is at high risk of suicide and does not wish to engage with CAMHS:

Seek guidance from your line manager and/or safeguarding lead
Consider contacting the young person’s parents/carers (unless child protection concerns preclude this), with agreement from the young person
Consult with CAMHS about what action to take next. CAMHS may offer to remain in contact with any such professionals to help them to work with the young person and their family.
Consult with CADS about what action to take next if young person who is at high risk of suicide will not engage with any professional

If you find yourself in this position you must share information and seek support and guidance from specialist agencies (as well as your line manager/safeguarding lead).

8. Engagement with parents and carers

Consider with the young person, how and when parents/carers can be contacted. When parents/carers are informed they can become part of the assessment, safety planning and risk management. Informing parents/carers can be very stressful for the young person. Some young people may be relieved that someone else liaises with their parents/carers and engages with them to be supportive.

Parents/Carers may need some additional advice on how to best support their child. Please see Appendix 4 for agencies that may be able to help, and Appendix 5 for national organisations/websites.

If the young person does not wish their parents/carers to be informed then workers should explore the reasons for this so that concerns of the young person may be able to be addressed. The worker should seek the support of their manager/supervisor. A consultation with CADS about whether parents should be informed as part of safeguarding the young person may be helpful.
If the young person has disclosed that their self-harm or suicidal thoughts/intentions are a response to alleged abuse by their parents/carers then workers should consult their line manager/safeguarding lead and follow their organisation’s procedures for reporting child protection concerns without delay
Consult with CADS about what action to take next if parents of the young person who is at high risk of suicide will not engage with any professional

9. Looking after yourself

When you are supporting young people with suicidal thoughts/feelings, it can be challenging and create a range of feelings in ourselves, such as anxiety, fear, confusion, sadness, frustration, hopelessness and powerlessness. You need to think about ways of looking after yourself when supporting young people in situations such as these.

Be sure you look after yourself by sharing your load with your manager/senior lead and ask for support when you need it.

These ‘Five ways to well-being’ may also be helpful to consider.

Connect…
With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in your local community. Think of these as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.

Be active…
Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance. Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.

Take notice…
Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.

Keep learning…
Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you will enjoy achieving. Learning new things will make you more confident as well as being fun.

Give…
Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, linked to the wider community can be incredibly rewarding and creates connections with the people around you.

(The New Economics Foundation, 2008)