1.4.35 Suicidal Behaviour

1. Introduction

Over half of people who die by suicide have a history of self-harm. However, the intention of self-harming is more often self-punishment, an expression of their distress or to relieve unbearable tension. Sometimes the reason is a mixture of these. People who self-harm don't usually want to die. They may self-harm to deal with life, rather than a way of trying to end it. Although many of the practice responses to children and young people who self-harm or try to end their life are the same, there are separate procedures to acknowledge the specific issues, motivations and warning signs.

2. Vulnerability to Suicide

Experts believe a number of factors determine how vulnerable a person is to suicidal thinking and behaviour. These include:

Life history – for example, having a traumatic experience during childhood, a history of sexual or physical abuse, or a history of parental neglect, having a parent or close family member who has died as a result of suicide;
Mental health – for example, developing a serious mental health condition, such as schizophrenia, bipolar disorder or severe depression;
Lifestyle – for example, drugs or alcohol misuse;
Employment – such as poor job security, low levels of job satisfaction or being unemployed;
Relationships – being socially isolated, being a victim of bullying or having few close relationships;
Genetics and family history;
A single stressful event may push a person "over the edge", causing suicidal thinking and behaviour. It may only take a minor event, such as having an argument. Or it may take one or more stressful or upsetting events before a person feels suicidal, such as the break-up of a significant relationship or being diagnosed with a terminal illness.

An American psychologist, Thomas Joiner (2005) [1], developed the Interpersonal Theory of Suicide. The theory states three main factors which can cause a person to feel suicidal. They are:

A perception (usually mistaken) they are alone in the world and no one really cares about them;
A feeling (again, usually mistaken) they are a burden on others and people would be better off if they were dead; and
Fearlessness towards pain and death.

The theory argues fearlessness towards pain and self-harm may be learnt over time, especially if regularly exposed to the suffering and pain of others, and which could explain the strong association between self-harming behaviour and suicide.

[1] Joiner, T.E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press

3. Assessing Risks and Warning Signs

You may feel that it is not part of your job role to carry out formal risk assessments when you are concerned that a child or young person is having suicidal thoughts; however all workers have a responsibility to talk to a child/young person who is experiencing difficulties in order to help them to access the support that they need.

If a child/young person tells you that they considering suicide you may be the first person that they have confided in. Young people have reported that the first time they speak to a professional they want to be treated with care and respect, but sometimes the response can actually make their situation worse, for example if suicidal thoughts are dismissed as attention seeking.

You may feel anxious about asking a child/young person if they are considering suicide; however it is important to talk about it even if you find it uncomfortable. It is a myth that you may put the idea into their head.

An assessment of risk should be undertaken at the earliest stage and should enquire about and consider the child or young person's:

Plans to hurt themselves or take own life;
If they are self harming, what is their intention? (E.g. is to help them cope or are they intending to take their life?);
Frequency of thoughts and actions;
Signs or symptoms of a mental health disorder such as depression;
Evidence or disclosure of substance misuse;
Previous history of self harm or suicide in the wider family or peer group;
Any delusional thoughts and behaviours;
Whether they are feeling overwhelmed and without any control of their situation;
Whether there is any online bullying and pressure to self harm/ commit suicide;
Whether the individual is part of a group 'pact' to harm themselves i.e. whether any other individual is also at risk of harm.

Any assessment of risks should be talked through with the child or young person and regularly updated as some risks may remain static whilst others may be more dynamic such as sudden changes in circumstances within the family or school setting.

The level of risk may fluctuate and a point of contact with a backup should be agreed to allow the child or young person to make contact if they need to.

If the young person is caring for a child or pregnant the welfare of the child or unborn baby should also be considered in the assessment.

The following warning signs suggest that the risk is high:

Thoughts of suicide are frequent and not easily dismissed;
Specific plan to complete suicide;
Any current self-harm, especially if it poses a risk to the child/young person's health and well being;
Access to the means to complete suicide (for example, stockpiling tablets);
Significant drug or alcohol abuse;
Situation felt to be causing unbearable pain or distress;
Previous, especially recent, suicide attempt;
Evidence of current mental illness;
Limited protective factors that may prevent them from attempting suicide or harming themselves, for example socially isolated or poor relationships with parents/carers;
No support mechanisms when distressed; and
ADHD / Impulsivity particularly where drug use is a factor.

Other warning signs

A person may also be at risk of attempting suicide if they:

Complain of feelings of hopelessness;
Have episodes of sudden rage and anger;
Act recklessly and engage in risky activities with an apparent lack of concern about the consequences;
Talk about feeling trapped, such as saying they can't see any way out of their current situation;
Self harm – including misusing drugs or alcohol, or using more than they usually do;
Noticeably gain or lose weight due to a change in their appetite;
Become increasingly withdrawn from friends, family and society in general;
Appear anxious and agitated;
Are unable to sleep or they sleep all the time;
Have sudden mood swings – a sudden lift in mood after a period of depression could indicate they have made the decision to attempt suicide;
Talk and act in a way that suggests their life has no sense of purpose;
Lose interest in most things, including their appearance;
Put their affairs in order, such as sorting out possessions or making a will.

4. Issues

4.1 Antidepressants and suicide risk

Some people experience suicidal thoughts when they first take antidepressants (see NHS website, Side effects). Young people under 25 seem particularly at risk.

4.2 Genetics and suicide

Suicide and some mental health problems can run in families. This has led to speculation that certain genes may be associated with suicide.

However, it would be too simple to claim there's a "suicide gene" as the factors leading to suicide are complex and wide ranging. Genetics may influence personality factors (such as acting impulsively or aggressively) that may increase the risk of suicidal behaviour, especially when a person is depressed.

4.3 Young men

Men may be more likely to avoid or ignore problems and many are reluctant to talk about their feelings or seek help when they need it.

A support group called the Campaign Against Living Miserably (CALM) is an excellent resource for young men who are feeling unhappy. As well as their website, CALM also has a helpline (0800 58 58 58).

Any assessment of the child or young person's needs and the risks they may be exposed to requires information to be gathered in order to analyse and plan support services. In order to share and access information from the relevant professionals the child or young person's consent will be needed; however, professional judgement must be exercised to determine whether a child or young person in a particular situation is competent to consent or to refuse consent to sharing information. In making this judgement, consideration should be given to the child's chronological age, mental and emotional maturity, intelligence, vulnerability and comprehension of the issues.

Informed consent to share information should be sought if the child or young person is competent unless:

The situation is urgent and delaying in order to seek consent may result in serious harm to the young person;
Seeking consent is likely to cause serious harm to someone or prejudice the prevention or detection of serious crime.

If consent to information sharing is refused, or can/should not be sought, information should still be shared in the following circumstances:

There is reason to believe that not sharing information is likely to result in serious harm to the young person 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 the prejudice to anyone which may be caused by the sharing; and
There is a pressing need to share the information.

Professionals should keep parents/carers informed and involve them in the information sharing decision even if a child is competent or over 16. However, if a competent child 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.

Where a child is not competent, a parent with parental responsibility should give consent unless the circumstances for sharing without consent apply.

6. Getting Help

Any child or young person who expresses thoughts about suicide must be taken seriously and appropriate help and intervention should be offered at the earliest point. All people working with children and young people must be aware of the potential for someone to commit suicide and must work together to ensure that no child or young person feels suicide is their only option.

Self harm can be a precursor to suicide and children and young people who deliberately self-harm may kill themselves by accident. See also Self Harm Procedure.

7. Protective and Supportive Action

A supportive response demonstrating respect and understanding of the child or young person, along with a non-judgmental stance, are of prime importance. Note also that a child or young person who has a learning disability may find it more difficult to express their thoughts.

Practitioners should talk to the child or young person and establish:

If they have taken any substances or injured themselves;
Find out what is troubling them;
Find out what help or support the child or young person would wish to have;
Find out who else may be aware of their feelings.

The following should be explored in a private environment, not in the presence of other pupils or patients depending on the setting:

How long have they felt like this?
Are they at risk of harm from others?
Are they worried about something?
Ask about the young person's health and any other problems such as relationship difficulties, abuse and sexual orientation or gender identity issues?
What other risk taking behaviour have they been involved in?
What have they been doing that helps?
What can be done in school or at home to help them with this?
How are they feeling generally at the moment?
What needs to happen for them to feel better?

Do not:

Panic or try quick solutions;
Dismiss what the child or young person says;
Believe that a young person who has threatened to harm themselves in the past will not carry it out in the future;
Disempower the child or young person;
Ignore or dismiss the feelings or behaviour;
See it as attention seeking or manipulative;
Trust appearances, as many children and young people learn to cover up their distress.

After exploring these issues it is necessary to understand the seriousness and immediacy of the risk.

8. Local Sources of Help

Bradford:
- Bradford District Care Trust - First Response;
- Bradford CAMHS.
Calderdale:
- CAMHS Referral Pathway;
Kirklees:
- CAMHS;
- Thriving Kirklees Single Point of Contact - Guide for Workers.
Leeds:
- Self Harm and Suicidal Behaviour.
Mindmate - Advice and Support for Young People in Leeds;
Wakefield:
- CAMHS;
- Wakefield – Children’s mental health.

9. Other Support

Many voluntary sector agencies offer support for young people in non-clinical settings, such as counselling or drop-in sessions – your local mental health directory or Public Health department should be able to provide you with information about local services. Nationally, Anna Freud National Centre for Children and Families and YoungMinds are good resources for helping children's wellbeing and mental health.

Online Support

Studies (e.g. Social Work and Social Media: Online Help-seeking and the Mental Well-being of Adolescent Males, British Journal of Social Work) have shown adolescents are more likely to seek help and support online, some favouring social networks and search engines over quality health sites. Young males who sought help from friends online recorded higher levels of mental health wellbeing. Professionals need to recognise this generational shift in help-seeking behaviour.