Suicidal Thoughts and Behaviours

We need to talk more about suicide and provide safe places for this to occur in a manner that is helpful and healthy. This includes paying careful attention to the language used to describe suicide so that it does not stigmatise, constrain thinking or restrict help-seeking behaviour. Terms such as kill/commit, succeeded, success and threat should be replaced with words such as 'end own life', 'took own life', 'talk about/show intent'.

Stigmatising language	Alternative
Committed suicide	Died by suicide
Succeeded in killing themselves	Took their own life
Tried to kill themselves	Attempted suicide
Talked about killing themselves	Talked about taking their own life

Suicide - In the UK, suicide is defined as deaths given an underlying cause of intentional self-harm or injury/poisoning of undetermined intent. (ONS, 2016)

Suicidal intent - This is indicated by evidence of premeditation (such as saving up tablets), taking care to avoid discovery, failing to alert potential helpers, carrying out final acts (such as writing a suicide note) and choosing a violent or aggressive means of deliberate self-harm allowing little chance of survival. Suicide intent can be hidden, not stated or stated; in these circumstances professionals should sensitively look for behaviours reflecting suicide intent (reflected intent). [2]

Postvention - Postvention refers to activities which reduce risk and promote healing after a suicide death. Although postvention is implemented after a suicide it is essential that we prepare for postvention before a suicide.

_{[1] stateofchildhealth.rcpch.ac.uk/evidence/mental-health/suicide
[2] Uncovering Suicidal Intent - A Sophisticated Art By Shawn Christopher Shea, MD | December 3, 2009}

For children and young people, it is important to have a three-pronged approach to suicide prevention through prevention, intervention and postvention support:

• Promotion of good mental health and wellbeing in a supportive, safe, and positive environment;
• Early intervention that will support early recovery, enabling self-help tools, access to effective interventions and referral processes;
• Postvention support to ensure that children, young people and staff receive bereavement and wellbeing support which is timely and effective to meet their needs and reduce their risk of suicide later (People bereaved by the sudden death of a friend or family member are 65% more likely to attempt suicide if the deceased died by suicide than if they died by natural causes).

For the mental health and wellbeing of children and young people the best approach is to ensure that we are providing positive messages and support to help them to have good mental health and be resilient. There are a number of services which can provide health and wellbeing support.

A service directory for professionals can be found here April 2023 v1 Mental Health Support: Guidance for professionals working with children and young people (CYP) (justtalkherts.org).

The Just Talk website has information and support on mental health and wellbeing. Please familiarise yourself with the website and explain to the child or young person what support and information is on the website. Please provide the child or young person with the link for the website and give support in navigating it if needed: Just Talk (justtalkherts.org).

Suicide Prevention in relation to a child or young person is concerned with recognising the signs that they might be having suicidal thoughts, being able to assess the child or young person and knowing where to access support and provide ongoing support.

The following key principles are drawn from the Hertfordshire Suicide Aware Prevention and Postvention Charter for schools:

• Ensure each child and/or young person is respected and listened to and involved in decision making around support, as appropriate to their development;
• Make children and young people aware of confidentiality & information sharing policies in relation to serious risk;
• Ensure the implementation of equal opportunities, understanding how some groups may be disproportionately affected by mental health and wellbeing needs;
• Commit to safe, open and honest dialogue about suicide and attempted suicide, carefully considering the language used;
• Understand that mental health and well-being support needs to be provided at different levels of a system (community, school, family and individual level). Please see the iThrive framework - a web guide;
• This is an animation explaining the iThrive framework.

It can be difficult to tell if a change in behaviour is part of growing up, or a sign that something else is affecting a child or young person. If the behaviour change continues over a longer period or the child or young person has stopped engaging in their usual activities, then it is worth checking in to see how they are. A staff member may also be approached by a child, a peer or a parent about their concerns.

Professionals should be curious about the following signs of distress:

• Changes in eating and sleeping habits;
• Withdrawing from groups;
• Displaying aggression towards others;
• Self-harming behaviour;
• Significant changes in mood, behaviour or personality;
• Decline in attendance;
• An increase or change in the nature of risk taking behaviours.

If you notice a child or young person is not themselves, don’t assume they’re talking to someone about how they feel. Showing you care and offering a listening ear empowers the child or young person to choose to speak to you, if they want. [3] Outward signs may not always reflect the feelings a person is experiencing so pay attention to your instincts also.

Internet Use

Internet use should be investigated by professionals, showing an interest in what websites and social media young people are using. Suicide-related internet use was reported in around 80 suicides by young people each year. This was most often searching for information about suicide methods or posting messages with suicidal content. There are also issues relating to pro-suicide groups which encourage dangerous behaviours. [4]

To understand more about risk factors and protective factors in the context of suicidal thoughts and behaviours, click here to view a guide. Please note, this is not a diagnostic tool.

If you feel concerned about a child or young person, or a child or young person has explicitly told you about suicidal thoughts, then it is important to have a prompt and direct conversation with them to assess the situation and their needs. This should take place to ensure the child or young person gets timely and appropriate support.

Information from this assessment should be documented in all records and case files.

_{[3] www.youngminds.org.uk/professional/resources
[4] sites.manchester.ac.uk/ncish/reports/suicide-by-children-and-young-people}

The following table can be used to help professionals reflect on the assessment and consider possible actions. Please note that the assessment is only valid at the time and can change.

	Thoughts/behaviour	Action
Early warning signs	Suicidal thoughts are fleeting and soon dismissed; No plan; Few or no signs of depression; No signs of psychosis (delusional thoughts and behaviours); No self-harming behaviour; Current situation felt to be painful but bearable.	Ease distress as far as possible. Consider any actions that could be taken to resolve difficulties; Link to other sources of support; including self-help resources (see Just Talk); Make use of line management or supervision to discuss particular cases and concerns; Review and reassess at agreed intervals; work towards establishing a trusting relationship; Consider completing a Family First Assessment; Consider further awareness of potential risk and protective factors.
Warning signs	Suicidal thoughts are frequent but still fleeting; No specific plan or immediate intent; Evidence of current mental ill health, especially depression or psychosis; Significant drug or alcohol use; Situation felt to be painful, but no immediate crisis; Previous, especially recent, suicide attempt; Current self-harm.	Ease distress as far as possible. Consider any actions that could be taken to resolve difficulties; Consider safety of young person, including possible discussion with parents/carers and professional network; Create a Safety Plan with the child or young person Seek specialist advice; Possible mental health assessment - discussion with, for example Child and young person Mental Health Service  or G.P.; Consider consent issues for the above; Consider increasing levels of support/professional input; Review and reassess at agreed intervals - likely to be sooner than if risk is low, maintain supportive relationship.
Increased warning signs	Frequent suicidal thoughts, which are not easily dismissed; Specific plans with access to potentially lethal means; Evidence of current mental illness; Significant drug or alcohol use; Situation felt to be causing unbearable pain or distress; Increasing self-harm, either frequency, potential lethality or both.	Ease distress as far as possible. Consider any actions that could be taken to resolve difficulties; Safety - discussion with parents/carers or professional network more likely; Create a Safety Plan with the child or young person Specialist CAMHS referral and conversation with Single Point of Access (SPA); Consider consent issues; If already open to mental health services, consider sharing information to clarify risk (with consent preferable but not essential if deemed to be child protection, let the CYP know it is your intention); Consider increasing levels of support/professional input in the meantime; Monitor in light of level of mental health service involvement, maintain supportive relationship.
Imminent risk If there is a physical need, call an ambulance; If there is not a physical need, call Single Point of Access (SPA) on 0300 777 0707; Make sure the child or young person is not alone; Remove anything the child or young person could use to take their own life. N.B. at any time during assessment and review emergency medical treatment may be found to be necessary or child protection concerns may be raised – see 3.5.3.

Mental health crisis means that a person is in a mental or emotional state where they need urgent help. They may be feeling at breaking point. Mental health crises may take the following forms:

• Suicidal behaviour or intention;
• Panic attacks/extreme anxiety, flashbacks;
• Psychotic episodes (loss of sense of reality, hallucinations, hearing voices);
• Other behaviour that seems out of control or irrational and that is likely to endanger the self or others (Mind).

Where there are concerns about imminent risk of suicide and/or a mental health crisis, follow the advice below from the Children's Crisis Assessment Team:

Important information to share with families:

• The quickest way to get mental health support at any time of the day or night in Hertfordshire is to call freephone number 0800 6444 101 or Call NHS 111 and select option 2 for mental health support;
• In Case of serious illness, injury or harm call 999 for emergency services;
• As a safety precaution – always ensure that prescribed and over the counter medicines are locked away securely at home.

When a child or young person is experiencing mental health crisis, this can be extremely distressing for them, as well as family members and professionals who are supporting them. Getting the right help at the right time in the right place is critical.

Serious Illness/Injury/overdose - Call Emergency Services
What to expect – Physical health tests and treatments will be completed at a general hospital and CCATT will assess mental health and risks in A&E.

Deterioration in mental health and known to mental health services
Please contact care coordinator or duty worker at the mental health team who are providing support Monday – Friday 9-5. Outside these hours – please contact Single point of Access (SPA) 0800 6444 101
What to expect – Mental health team will advise further based on information provided and their knowledge and involvement with the child and family including safety planning and any further assessment or increase in support required during period of crisis.

Deterioration in mental health and not known to mental health services
Please contact Single point of Access (SPA) 0800 6444 101
What to expect – A telephone triage will be completed by SPA and they will advise based on the information provided. This could include safety planning, a referral to CAMHS (including urgent referrals) or a telephone assessment by the crisis team.

CCATT Crisis Telephone assessment
What to expect – once a telephone triage has been completed by SPA, if indicated a call back will be made usually within 1 hour by a crisis team clinician. An initial assessment will be undertaken by phone. The clinician will advise based upon the information provided. This could include safety planning, same day/next day face to face crisis assessment in the community, initiate referral to mental health services or to attend A&E.

When supporting a child or young person who is showing suicidal behaviour it is important to provide some immediate support whilst also signposting to relevant services.

Providing a brief intervention with the child or young person by developing a safety plan is one key element in the support process. A safety plan allows a child or young person to stay safe when having suicidal thoughts by setting out how they would like to be supported and how they can help themselves stay safe. It is also a place to keep important information and contacts for when they need it. A safety plan should not be created during a time of crisis but when the child or young person is in a safe calm environment which allows them to think clearly about what to put into their plan.

Suicide Safety Plan from Papyrus, UK Charity for prevention of young suicide. This plan is specific for suicidal ideation and reducing risk.

The NHS website also link to stayingsafe.net with lots of videos and resources about safety planning which is good for professionals to review and / or to direct adults experiencing suicidal thoughts.

Another type of intervention that could be used is the Wellness Recovery Action Plan. This is a framework to develop an effective approach to manage distressing symptoms and understand behaviour. It can be used to help the child or young person have more control over their problems. Wellness Recovery Action Plan (getselfhelp.co.uk). This plan is more general and holistic. It is useful when risk is lower.

On-going support systems need to be put in place irrespective of the level of risk taking into account that the level of risk could change.

On-going support may take many forms and may be offered via numerous sources and will be dependent on the child or young person's needs and wishes. It is important to ensure there is a professional in the child’s system who has ongoing oversight of the support being given.

Where the assessment does not lead to referral for more in depth assessment it is essential that communication with the child or young person remains strong and that a supportive adult remains in contact with the child or young person on a regular basis.

If a child or young person has been admitted to hospital, mental health services might continue to offer support, but equally the school/college nurse, the child's GP, or in some cases the child's social worker, may be best placed to offer on-going support. One key worker should be named and identified to offer an on-going point of contact for that child, with an alternative person stipulated should the key worker not be available. This needs to be agreed locally between key professionals and in consultation with the family and child or young person. A planning meeting may need to be convened for this purpose, and further review meetings where required.

It is also acknowledged that parents / carers, staff and other pupils may require support themselves when supporting children or young people at risk of suicide (see staff wellbeing section).

There are a number of providers delivering mental health support to children and their families in Hertfordshire. Before making a referral to Specialist CAMHS, please consult this service directory to explore the level of mental health need and appropriate interventions and providers: April 2023 v1 Mental Health Support: Guidance for professionals working with children and young people (CYP) (justtalkherts.org).

It would be helpful to discuss the options with the child or young person and agree which service they are most comfortable to engage with. Some of the services require a professional referral which can be completed by any professional (it does not need to be the GP) and others are accessed via self-referral. Professionals may wish to help self-referral processes by either helping with forms, creating a space for a phone call etc. if desired.

It is possible that the first time any community health or education professionals learn of a child or young person in need may be after attempted suicide that has resulted in assessment in Accident and Emergency or admission to hospital. Irrespective of the entry point to the Referral Pathway, where a child or young person has been deemed to need a mental health assessment, it is essential that we do not lose sight of that person post assessment. For children and young people accessing non statutory mental health and wellbeing services, it is also important to check in on engagement and outcomes with the young person, particularly for the nominated lead professional.

If a child or young person is deemed to need support from other professionals the staff member supporting the child or young person will:

• Seek consent from the child or young person to share information;
• Tell the child or young person what information will be shared, why it should be shared and the consequences of sharing.

Sometimes concerns of significant harm may lead to a referral being made without consent. Please note, referrals to non-crisis mental health services require consent from the parents or competent child.

3.5.1 Parental consent

Professionals should encourage children and young people to make their parents aware of their thoughts and feelings. The professional could support or facilitate this conversation if the child or young person desires. The majority of parents will want to support their child; they may require information or support to understand the situation and how best to help. However, if a competent child or child over 16 wants to limit the information given to their parents or does not want them to know it at all; the child's wishes should be respected, unless the conditions for sharing without consent apply.

3.5.2 Guidance on Sharing Information

In line with Hertfordshire Continuum of Need for Children and Young People and consistent with Working Together to Safeguard Children every family (child/young person and their parent/carer) has the right:

• To be told when a professional is worried about the safety or wellbeing of their child by that professional;
• To have their consent obtained when someone wishes to make a request for support on their behalf;
• To be front and centre of the plan to keep their child safe and well.

Purpose of Sharing Information

The purpose of sharing information is to ensure young people in need and in particular young people who have suicidal thoughts and behaviours or are perceived to be at risk of suicide are given the help and support they are entitled to.

What will be shared?

Information shared will be no more than is necessary. All information will be handled with respect and care.

Unrecorded observations, which may not at first seem significant, will be freely shared on a need-to-know basis within statutory agencies and between partners in the interests of meeting the statutory functions of the partners.

Information, particularly how judgments and decisions were reached should be recorded if it is significant.

Consent

The Hertfordshire Continuum of Need for Children and Young People guidelines are intended to strengthen the respectful relationships that we build as professionals with families, including transparency and honesty about concerns and the help and support needed for a child or young person to thrive and be safe.

Where partner agencies are requesting additional and intensive services, targeted early help or child in need support for a family, this must include parental consent to be accepted by Hertfordshire’s multi agency safeguarding hub, the Gateway. Consent to make a request for support on their behalf should also be sought from the children and young people, wherever they are of an age and level of understanding to give it.

Where referrals are made for Specialist services because a practitioner believes a child is suffering, or is at risk of suffering, significant harm, it is good practice to seek parental consent and it will usually be appropriate to do so.

For a small number of children, seeking parental consent would not be appropriate if the child would be placed at increased risk of significant harm through the action of gaining this consent, there would be an impact on a criminal investigation or a delay in making the referral would impact on the immediate safety of the child.

The Gateway will inform referrers if they have submitted a contact or referral that is missing the necessary parental consent. No record of these contacts or referrals will be held by the Gateway. The referrer will need to submit a fresh contact or referral once they have secured parental consent. 

Sharing without Consent

Informed consent should be sought from the competent child to share recorded information unless;

• The situation is urgent and there is not time to seek consent; or
• Seeking consent is likely to cause serious harm to someone or prejudice the prevention, detection of serious crime.

If consent to sharing recorded information is refused by the competent child, or can/should not be sought from the child, information should still be shared in the following circumstances;

• There is reason to believe that not sharing is likely to result in serious harm to the child or someone else or is likely to prejudice the prevention or detection of serious crime; and
• The risk is sufficiently great to outweigh the harm or prejudice to anyone that may be caused by the sharing; and
• There is a pressing need to share the information.

When is a child "competent" to give consent?

Consent for information sharing: Anyone under the age of 18 is a child. A judgement must be made as to whether a particular child in a particular situation is competent to consent or refuse consent to sharing information. Consideration should include the child's chronological age, mental and emotional maturity, intelligence, vulnerability and comprehension of the issues. A child at serious risk of suicide may lack emotional understanding and comprehension (Gillick Competence should be used).

Consent for treatment: The Mental Capacity Act 2005 - Capacity and consent in 16 and 17 year olds

The Mental Capacity Act (MCA, 2005) applies to young people aged 16 years and over and in law they are presumed to have capacity to consent to or refuse treatment, including hospital admission. Mental capacity is present if a person can understand information given to them, retain the information given to them long enough to make a decision, can weigh up the advantages and disadvantages of the proposed course of treatment in order to make a decision, and can communicate their decision.

Parents cannot override consent or refusal from a competent 16/17-year-old. Neither can they consent on behalf of their competent 16/17-year-old. However, the Department of Health recommends that it is good practice to encourage children of this age to involve their families in decisions about their care, unless it would not be in the child’s interests to do so.

16 and 17-year-olds who do not have capacity

If a child lacks the capacity to consent, they may be treated without their consent under the MCA as long as the treatment does not involve a deprivation of liberty. Treatment can also proceed with the consent of someone with parental responsibility as long as the treatment falls within the scope of parental responsibility. While only one person with parental responsibility needs to be approached, it is good practice to involve all those close to the child if possible. The definition of ‘parental responsibility’ is set out in the Children Act 1989.

Children under the age of 16 years who are competent

For children under 16 years the MCA does not apply. Instead, a child needs to be assessed whether they have enough understanding to make up their own mind about the benefits and risks of treatment – this is termed ‘Gillick competence’. Parents cannot override a competent child’s refusal to accept treatment. Where a competent child under 16 refuses a specific treatment which is in their best interests, but the parents support the recommendation for treatment, there should be evidence that providers have attempted to understand both the child’s and parents’ position. There should also be evidence that alternative treatments have been considered or a compromise is not possible. However, ultimately the decision rests with the competent child (CQC, 2020 Brief Guide Capacity and consent in under 18s v3).

3.5.3 Child Protection

After the risk assessment, or at any stage of the care pathway, if a professional is concerned that the child or young person is in need of protection, they should call the Customer Call Centre on 0300 123 4043. For out of hours service (after 8 pm) calls will automatically be diverted to an agency, who can contact the Children's Services Out of Hours Service (SOOHS) on your behalf (except textphone/minicom, callers need to redial 01992 632150).

The usual child protection procedure should then be followed whereby a section 47 enquiry / assessment will be carried out by Children's Social Services in consultation with the Police and other agencies.

4.1.1 Schools Training

It is recommended that all Hertfordshire schools nominate a Mental Health Lead to access the following training and resources:

• Mental Health Leads training is available to all education settings in Hertfordshire. Dates are sent out throughout the year and places can be booked by e-mailing: hweicbhv.schoolsmh@nhs.net;
• The training aims to provide Mental Health Leads with the tools to plan and action a whole school approach to emotional and mental wellbeing;
• The Level 2 Mental Health First Aid training course can also be booked by e-mailing: hweicbhv.schoolsmh@nhs.net;
• Senior Mental Health Leads training is also available via the DofE. See GOV.UK, Senior mental health lead training.

4.1.2 Suicide Prevention Training for All

The Suicide Prevention website provides information on training available within Hertfordshire.

4.1.3 Staff Wellbeing and Supervision

When supporting issues like suicide and related issues it is really important that staff prioritise their own wellbeing and are supported to do so. It is impossible to provide effective support to others if your own wellbeing is low. Burnout, compassion fatigue and blocked care can occur when staff are not adequately supported, and this need is heightened at stressful times such as following a suicide or attempted suicide.

The following links provide quality assured funded resources to support staff wellbeing:

• Schools in Mind: Resources (annafreud.org);
• Mentally Healthy Schools;
• Mental Health at Work;
• Mindful Teachers;
• Education Support partnership;
• Staff wellbeing booklet (annafreud.org).

Parents may also need to access support for themselves in order to provide the best support they can to their children. Parents of children with mental health and wellbeing needs can access a support service from NESSie.