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2.28 Safeguarding Children and Young People with Suicidal Behaviour


Contents

  1. Introduction
  2. What is Suicidal Behaviour?
  3. Why do Children and Young People feel Suicidal?
  4. Risk Indicators that a Child or Young Person may be Thinking about Suicide
  5. Children and Young People whose Lives are in Immediate Danger
  6. Consent
  7. Children and Young People who Have Made Plans to Die
  8. Suicidal Children and Young People who feel Their Lives are Hopeless and that Death would be Preferable
  9. Working with a Child or Young Person you Suspect may be Having Suicidal Thoughts
  10. Ongoing Work with the Young Person
  11. Additional Resources


1. Introduction

Suicidal behaviour is a complex phenomenon that usually occurs along a continuum, progressing from suicidal thoughts, to planning, to attempting suicide, and finally dying by suicide. Suicidal behaviour (fatal and non-fatal) in adolescents is often associated with a psychiatric disorder, and often unrecognized or untreated. More than 90% of adolescents who die by suicide suffered from an associated psychiatric disorder (mood disorder and substance or alcohol abuse) at the time of their death and more than half had suffered from a psychiatric disorder for at least 2 years. Suicidal behaviour frequently co-occurs with other health risk behaviours such as binge eating, binge drinking, tobacco use, weapon carrying and having unprotected sex. (International Association for Suicide Prevention).

Safeguarding and promoting the safety and welfare of children and young people where there are particular concerns about suicidality is a shared responsibility, and is dependent upon effective joint working between agencies and professionals that have different roles and expertise. Effective multi-agency relationships and good information sharing processes are crucial, so that the vulnerability and risk factors for individual children and young people may be properly understood and responded to.

Schools, social care and the youth justice system, as well as charities highlighting problems such as bullying, substance misuse, domestic violence, low body image and lack of self-esteem all have an important contribution to make to suicide prevention among children and young people.

Post-suicide community-level interventions can help to prevent copycat and suicide clusters. This approach may be adapted for use in schools, workplaces, health and care settings. For more information see Samaritans in Schools.


2. What is Suicidal Behaviour?

Suicide ideation refers to the cognitions (thought processes) surrounding the act of suicide. These include the reasons for wanting to die; the planning of the event; and the effect of the suicide on others who are significant in the person’s life.

Self-destructive behaviour refers to acts of harm against oneself or others. These behaviours are often displayed without any evidence of remorse or pain, and may be indicators of a rehearsal for the final act.

Suicide attempt refers to significant, life-threatening harm inflicted on oneself. The individual survives the suicide, usually through being discovered by another and receiving rapid medical attention.

These definitions are from Colquhoun, Child maltreatment, sexual abuse and suicide attempts © NSPCC 2009.


3. Why do Children and Young People feel Suicidal?

The children and young people who talked to ChildLine (NSPCC, 2009) about feeling suicidal were usually in turmoil and were facing a range of problems in their lives, the combination of which had left them feeling desperate and unable to cope. What many of these children and young people had in common was that they were lonely, had very low self-esteem and they thought that no one cared about how they were feeling.

Children told ChildLine (NSPCC, 2009) that the most common causes for their suicidal feelings are abuse, bullying, family upheaval, relationship breakdowns, exam stress and mental health problems in themselves or in members of their family.

In addition, research has shown that the following circumstances can put children and young people at greater risk of suicide:

  • Loss, bereavement or the break-up of a relationship;
  • Living in an isolated rural area;
  • Going to prison;
  • The experience of racism or a culture clash;
  • Struggling with sexual identity;
  • A history of suicide in the family;
  • Illness or disablement;
  • Previous suicide attempts;
  • Stress and anxiety relating to work, school or home;
  • A combination of any of the above.


4. Risk Indicators that a Child or Young Person may be Thinking about Suicide

The following signs may be present when a child or young person is thinking about taking their own life:

  • Talking about methods of suicide;
  • Dwelling on insoluble problems;
  • Giving away possessions;
  • Hints that “I won’t be around” or “I won’t cause you any more trouble”;
  • Changes in sleeping or eating habits;
  • Withdrawal from friends, family and usual interests;
  • Violent or rebellious behaviour, or running away;
  • Drinking to excess or misusing drugs;
  • Feelings of boredom, restlessness or self-hatred;
  • Failing to take care of personal appearance;
  • Complaints about headaches, stomach aches, tiredness, or other physical symptoms;
  • Becoming over-cheerful after a time of depression;
  • Unresolved feelings of grief following the loss of an important person or pet (including idols, such as pop stars and other “heroes”).


5. Children and Young People whose Lives are in Immediate Danger

See Flowchart for Action for Safeguarding Children and Young People with Suicidal Bahaviour

If a worker or practitioner from any agency is working with a child or young person who says they have already taken action to harm themselves, it is essential that the worker takes this seriously and acts immediately. DO NOT DO NOTHING.

The worker should assess as quickly as possible how dangerous the action has been, for example, by contacting the local poisons unit to discover if an overdose of a particular drug is life-threatening.

If the young person’s life is at risk, the worker should explain that because they care about the young person and believes that their life is precious, the worker will take action to save them.

The action is fully explained to the young person, and if possible the young person’s permission should be obtained to act. However, even if permission is refused, because the young person’s safety is paramount, this is one of the few circumstances in which confidentiality is breached and medical or other help is urgently sought.

The worker will ring emergency services (999) for an Ambulance if necessary. Continue to assess dangerousness of actions and gather information from the young person if possible. Speak to line manager / supervisor or Designated Safeguarding Lead if they are immediately available without leaving the young person.

Wait with the young person until emergency services arrive. The young person should be taken to the nearest Accident & Emergency Service for assessment and treatment. Parents/carers should be informed. If the young person is a Looked After Child, their social worker and Independent Reviewing Officer should also be informed.

A decision will then be made by health professionals as to whether they require hospital assessment or treatment or whether they can be discharged to the community. In either case, a mental health assessment should be conducted by the CAMHS team (or Adult Mental Health Team if the young person is over 16 years). The young person MUST NOT be discharged before this assessment is completed by the relevant mental health professional.

A risk assessment should be completed. Assessment should be undertaken by healthcare practitioners experienced in this field and should include a holistic assessment of the family, their social situation, family history and any potential child protection issues. A treatment plan should be agreed between the child or young person, their family, professionals already involved in their lives and nominated support people. This should form the basis of the discharge support plan or ongoing support plan if they have remained in the community.

If the person who made the referral is not part of the assessment process, ensure they are included in feedback as the child or young person may choose to seek them out in the future.

If the young person discloses abuse or neglect, the Referrals to Children’s Social Care procedure must be followed. Safeguarding advice should be sought about whether or not a Strategy Meeting and Child Protection Conference threshold is met.


6. Consent

Many professionals may be concerned about acting against the wishes of a child or young person whom they may consider to be “Fraser Competent”. It is important in these instances for the worker to consider:

  • A young person can only be considered competent to accept treatment, and is not considered competent to refuse treatment;
  • The child or young person may not be able to make sound decisions at that time; particularly when there is a risk to themselves they do not fully understand.

If the child or young person actively refuses to consent to transfer to hospital for emergency assessment, the police should be called to assist. Police have powers under the Mental Health Act (MHA 1983) to take children and young people to a Place of Safety in these circumstances.

Consent should be obtained from the child or young person if the situation is not immediate or urgent.


7. Children and Young People who Have Made Plans to Die

If a child or young person has made a suicide plan but is not deemed to be in immediate danger, the worker should ask if the young person has the means to put the plan into action, for instance, has obtained enough tablets for an overdose or has a knife or noose. If so, the worker should attempt to persuade the young person to separate themselves from the means of taking their own lives, for instance, by asking to take control the pills or relinquish the knife or other weapon.

The worker should then make it clear that they want to listen to the young person’s thoughts and feelings, trying to connect with the part of the young person that wants to live, while acknowledging the part that wants to die.

The crucial task of the worker in these cases is to assure the young person that they are being heard and taken seriously. The young person may have chosen the worker as their last resort, believing that no one else in their lives cares whether they live or die. It is the workers’ role to assure them that they care.

If the young person does not relinquish their plan, the worker may need to contact the emergency services and follow the procedure outlined in section 5 (Children and young people whose lives are in immediate danger) above.


8. Suicidal Children and Young People who feel Their Lives are Hopeless and that Death would be Preferable

If a young person reports that they are having suicidal thoughts, but have not yet put them into action, the worker should always take them seriously, ensuring that the young person understands that they care about them, and that they feel properly heard. The worker should explore with the young person what makes them feel so hopeless, and why they feel that death is preferable.

Provided that the young person is not at immediate risk, the worker should make it clear that they want to listen, and will explore with them the negative and the positive aspects of their lives, focusing on the positives, exploring options and, where possible, finding solutions and discovering what support networks are available to them. For example, a young person who is in despair because of bullying may ask that a call is made to the school; or a young person whose life is being damaged by parental drug or alcohol abuse may wish to be referred to a relevant support group, or to Children’s Social Care.

These referrals would be made with the consent of the young person, and full information offered to the young person, sometimes by means of a conference call with the agency or team involved.

If the young person discloses abuse or neglect, the Referrals to Children’s Social Care Procedure must be followed. Safeguarding advice should be sought about whether or not a Strategy Meeting and Child Protection Conference threshold is met.


9. Working with a Child or Young Person you Suspect may be Having Suicidal Thoughts

The following advice is from Children talking to ChildLine about suicide: NSPCC, 2009

If you suspect a child or young person is in difficulties but they are withdrawn or uncommunicative, try the direct approach:

  • Ask “How do you feel?” or “How bad do you feel?”
  • Say “Some people feel suicidal; do you ever feel like that?”

The child or young person may leave the room or ignore you, but you should ask anyway. It is better to give some reassurance that you are concerned than to give the impression that you do not care.

If questions get you nowhere, try the following:

  • Say “I’m concerned about you”
  • Say “I know you are having a bad time at the moment”
  • Let the child or young person set the agenda for discussion on their own terms;
  • Be patient and sympathetic; children and young people may not be able to articulate how they feel;
  • Help the child or young person discuss his or her options, offering solutions and alternatives;
  • Enable them to talk both about what led them to feel like this, and what they might look forward to in the future;
  • If they still will not communicate with you about how they feel, suggest they might talk in confidence to another person - a trusted family member, another trusted adult, such as a teacher, or a friend. You might say: “If you can’t or don’t want to talk to me, who you think you might talk to? What about ChildLine, for instance?”


10. Ongoing Work with the Young Person

All professionals involved in the life of the young person should be made aware of the suicidal behaviour in order to increase protection in the future. It is important to maintain communication and support to the young person and ensure they have a safety plan if they have suicidal thoughts in the future.

Workers may want to consider routinely screening for suicide early on in their assessment, rather than avoiding the subject until the child or young person voluntarily discloses their thoughts during the course of therapeutic intervention. This may be a more proactive way of engaging the individual and deterring subsequent suicide attempts.

Workers should consider the relationship between self-harm and suicide. The worker should consider whether the act of self-harming is a sufficient release for the individual or whether there is a risk of self-harming with suicidal intent. See Safeguarding Children and Young People who Self-Harm Procedure for more information.

Due to the link between substance misuse and self-harm and suicide, it is recommended that workers working with these vulnerable young people examine ways of employing drug prevention strategies as part of their intervention together with the prevention of self-harming and suicide.

Workers should also advise parents where applicable of the need to be aware of the websites their children are visiting and install software to prevent access to certain parts of the internet.


11. Additional Resources

Child and Adolescent Mental Health Service (CAMHS)

Young Minds: Provides information and advice on child mental health issues

Childline: Provides a free and confidential telephone service for children. Helpline: 0800 1111. Supporting Children at Risk of Suicide.

Samaritans: Telephone support for adults and under 18's who are experiencing difficult feelings. They provide a 24-hour service offering confidential emotional support to anyone in crisis. Helpline 08457 909090 (UK)

Papyrus - website and organisation which supports the prevention of young suicide

Winston’s Wish - bereavement support for children and young people

Cruse Bereavement Care - children

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