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The term ‘risk’ covers a number of aspects, including risk to self, risk to others and risk from others. A risk is defined by how likely it is that the negative event will occur, how soon it is expected to occur, and how severe the outcome would be (Morgan, 2000). For the purpose of this essay, I will be focussing on the assessment and treatment of risk to self, specifically self-harm (SH) and suicide in children and young people (CYP) services. This essay aims to discuss ways psychological theory and research inform current practice in the assessment and treatment of risk, the various challenges involved and the implications that this has for clinicians and services. CYP services in this
essay will refer to Child and Adolescent Mental Health Services (CAMHS) which are multidisciplinary services that have a particular role and delivering specialist mental health care to CYP under 18 years old.
There is considerable definitional ambiguity around the term SH. The controversy is
around whether there is any underlying suicidal intent of the SH or not. This essay
will adopt the definition by the National Institute for Clinical Excellence
(NICE) who define SH as ‘any act of self-poisoning or self-injury carried out
by an individual irrespective of motivation’ (NICE Guidelines, 2013, p.6).
1.2 Prevalence and vulnerable groups[VR(CPT1]
SH and suicide are major public health concerns in adolescents (Gore et al., 2011). Currently, suicide is
the second most common cause of death in CYP worldwide (World Health
The organisation, 2014), and nationally suicide is one of the leading causes of
death in adolescents (Hawton et al., 2002).
SH occurs in both children and adolescents, and is rising. Morgan et al. (2017)
reported a 68% increase in SH among girls aged 13-16 between 2011 and 2014. SH
in younger children is relatively low and increases dramatically as children
reach adolescence (Hawton et al., 2003). However, it is difficult to estimate
rates of SH in children under 12 years old since little research has focused on
this age group (Hawton, Saunders & O’Connor, 2012a). For many CYP SH is a
coping strategy that occurs without suicidal intent. However, it is often repeated which increases the risk of completed suicide compared to the general population (Hawton & James, 2005).
Morgan et al. (2017) reported that CYP who harmed themselves were nine times
more likely to die unnaturally during follow up, with the notable increase risk of
Particular groups of CYP are at greater risk of SH, including children with Autism
Spectrum Disorder and learning difficulties (Singh et al., 2006). CYP who have
experience of care is not only more likely to SH, but are also at greater risk
of both attempted and completed suicide (Vinnerljung et al., 2006). There is the sparse and inconsistent literature of SH in ethnic minority groups. Hawton et
al. (2002) found a lower risk of SH in Asian girls, yet Bhugra et al. (2003)
reported that Asian girls aged between 10 and 14 years had higher rates of SH
when compared to White British girls of the same age. Ethnic minority groups
are also less likely to be referred for specialist psychiatric and outpatient
services following SH than white females (Cooper et al., 2010[VR(CPT2] ).
SH is associated with higher rates of depression and anxiety (Morgan et al.,
2017). In completed suicides, 90% of adolescents had been diagnosed with a psychiatric
disorder (Bridge et al., 2006). Although not a diagnosable mental health
problem, the latest edition of the Diagnostic[s3]
and Statistical Manual of Mental Health Disorders (5th edition;
DSM-5[VR(CPT4] ; American Psychiatric Association [APA],
2013) features ‘Personal history of self-harm’
in ‘V-codes’. Although these codes are not a diagnosis in itself, it
represents an important shift in how we think about SH and emphasises that it
is a relational difficulty[VR(CPT5] .
1.3 Government initiatives
Given the considerable increase in SH and suicide in CYP over the last few decades (Hawton
et al., 2002), it is not surprising that
improving children’s mental health and prevention of suicide is a focus of
national strategies[s6] .
The ‘Future in Mind’ report (Department of Health [DOH], 2015) set out ambitions
for improving CYP’s mental health and wellbeing over the next five years. This
included making better links between schools and specialist CAMHS, and a
commitment to investing funds to roll out the Children and Young People’s ‘Improving
Access to Psychological Therapies’ programme. Building on this report, the DOH
and Department of Education green paper published in December 2017, sets out measures
to transform CYP’s mental health provision by focusing on earlier preventions
and intervention, particularly within schools and colleges. The plans are currently under
1.4 Service context
All CYP services in the United Kingdom are legally bound to clinical governance,
which includes the management of clinical risk. NICE (2011) guideline 1.4.1
states that CAMHS should generally be responsible for the routine assessment of,
and the longer treatment and management of SH in CYP. By carrying out a
thorough risk assessment, children’s services can make a difference to the quality
of life of children and families by preventing or minimising risk.
In the assessment and treatment of SH in CAMHS, special attention should be paid
to issues of confidentiality, the young person’s consent, parental consent,
safeguarding and the use of the Mental Health Act.
It is the statutory responsibility of all adults to keep CYP safe from harm. The
Gillick competency and Fraser guidelines help clinicians to balance CYP rights
and wishes with the responsibility to keep them safe from harm[VR(CPT7] .
A biopsychosocial assessment that combines the evidence base for
risk and protective factors and an assessment of need is recommended for CYP
presenting with SH (Royal College of Psychiatrists[VR(CPT8] [RCP], 2010).
CYP services across the country do not have a standardised risk assessment. The DOH
(2007) and the RCP (2010) encourage services to adopt a ‘structured clinical
judgment’ approach to assessing risk which involves the use of clinical
judgment, guided by a semi-structured format and risk assessment tools.
Information is gathered through interviews with the young person, family members,
professionals involved in the individuals care, and by reviewing available
A risk assessment is conducted in order to identify the intention, function and motive
of the SH. The level of risk is defined by the likelihood, imminence and
severity of any further SH, and is generally categorised as a low, medium or high
risk. Throughout, it is essential that the young person is asked directly about
suicidal ideation, including any plans to complete suicide, the availability of
means to kill themselves and deterrents.
The aim of the risk assessment is to develop a formulation which, in turn, informs treatment[VR(CPT9] . Clinical psychologists within CYP
services are particularly valuable given their skills in psychological
formulation and their ability to integrate a theoretical understanding of the
causes and psychological functions of SH, risk assessment information,
alongside an understanding of the systemic influences of risk in CYP. Conducted
well, a risk assessment is more than just a process, and that in itself can be
the beginning of support and treatment (Kapur et al., 2013). Therapeutic
assessment has been found to increase adherence to subsequent treatment
compared to treatment as usual (Hawton et al., 2015).
2.1 Risk factors
Assessment of risk in CYP should draw on the evidence base regarding the known factors that
increase the risk for SH and suicide in this age group (DOH, [VR(CPT10] 2007; RCP, 2010). Where there are a number
of underlying risk factors present, the risk of further self-harm is greater
(Hawton et al., 2012a[s11] ).
Risk factors for SH can be divided into static and dynamic factors. Static risk
factors are those that are fixed, such as adverse childhood experiences, including
abuse and loss. A history of
maltreatment is one of the most salient risk factors for paediatric SH (Finzi et al., 2001), however much less is
known about this group than adolescents. Research shows that exposure to others
suicidal behaviour, particularly in members of the family increase risk for SH
and suicide in young people (Hawton & James, 2005).
Dynamic risk factors are those that change over time and can be aspects of the
individual or of their environment and social context. This is particularly important
in the context of CYP since they are heavily influenced by the systems that
surround them. Bullying, cyberbullying and social isolation is particular risk
factors for SH in CYP (Hawton et al., 2012a). Adolescents are also vulnerable
to media influences. Hawton & Williams (2001) discuss how CYP that feel
suicidal may access online sites that encourage the suicidal behaviour. Such factors
have been found to have a significant impact on both triggering and maintaining
SH, and should be carefully considered throughout assessment (Hawton et al.,
Dynamic risk factors can also include some of the psychological elements of the biopsychosocial
assessment that may change over time. Joiner’s interpersonal theory of suicide
has been adopted by many CAMH services in England, and although an adult model[VR(CPT12] , it is still applicable for CYP (Barzilay
et al., 2015). According to the theory, there are three components ‘thwarted
belongingness’ ‘perceived burdensomeness’ and ‘capability of suicide’, that if
present simultaneously produces the desire for suicide (Joiner, 2005).
Assessment of risk should explore these areas with CYP, as if they fulfil these
components, Joiner would suggest that an individual is at high risk of suicide[VR(CPT13] .
2.2 Protective factors
The research on [VR(CPT14] protective factors in CYP is somewhat limited,
however, known protective factors include social attachment to family (Carter
et al., 2007), and school (King, 2008). Although often discussed as a risk
factor for SH in CYP, social media may also be protective in some CYP (Daine et
al., 2013). Furthermore, Speckens and Hawton (2005) highlight that the emotional
and cognitive skills some CYP possess can be protective against engaging in SH,
such as greater problem-solving skills, self-control, self-efficacy and
positive future thinking. It is important to note that a change of protective factors
can be a risk factor, for example, the loss of a relative, parental separation
and transitions (Mclean et al., 2008).
2.3 Assessment of need
SH can be a transient behaviour in CYP that is triggered by particular stressors
and resolves fairly quickly, an age limited behaviour which stops as CYP move
into adulthood or part of a long-term pattern of behaviour that is associated
with more serious mental health difficulties (Hawton et al., 2012a; Young et
al., 2007). Thus, it is recommended that the assessment should aim to establish
whether there are any underlying mental health difficulties present (RCP, 2010). By not addressing the underlying
difficulties, CYP may develop a greater perception of isolation and
disconnectedness, thus increasing risk (Furnivall, 2013).
In addition, child sexual and physical abuse is associated with SH and suicidality
(Fortune et al., 2007). SH in CYP may be a symptom or marker of abuse and it is
important that practitioners remain mindful of the ‘bigger picture’ and of
potential safeguarding concerns when assessing risk in CYP services.
2.4 A systemic approach
When working with CYP, it is extremely important to consider the
systemic influences on the individual in relation to risk[VR(CPT15] . A risk in CYP should
be viewed in the broader environmental and relational context of the CYP.
However, the context is often
complex, and since CYP have mental health, social, family and
educational needs, it is important that there is a joined-up approach between services[VR(CPT16] . Indeed, lack of communication of risk
between services is often highlighted as an area for improvement following
incidents relating to risk.
In CAMHS, it is commonplace that family members are involved in conversations
about risk. This is particularly helpful because they are able to provide
information about the child’s general functioning, home and school environment,
and any recent difficulties or stresses that the child may not be able to
Carr (2009)[VR(CPT17] suggests that CYP who SH, particularly
those who have attempted suicide should have both an individual and[VR(CPT18] family assessment. This is important in
CYP services since family factors are key risk factors associated with SH in
CYP (Sutyemoto, 1998). Poor parent-child attachment (Fergusson et al., 2000),
perceived low levels of parental caring and communication are related to
increased risk of SH among CYP (Wagner, Silverman & Martin, 2003).
Furthermore, parental depression and exposure to SH and suicidal behaviour in
others have been found to be the significant risk factor for childhood suicidal
behaviour (Shaffer, 1974). Very little research has focussed on family risk
factors for ethnic minority groups. However, Thompson & Bhugra (2000)
suggest that cultural conflict is an important consideration in assessment./p>
Messer and Fremouw (2008) discuss different systemic theories of SH in CYP. Firstly,
they highlight that exposure to SH from others may provide a behavioural model
which increases the probability that thoughts of SH are acted upon. Rather than
a modelling response, they also discuss how individuals within the system may
have shared stressors, and that the SH may serve as a response to shared
stressful life events. As
such, SH and suicide behaviours may be reinforced and maintained by the
continuation of interactions within the system.
Softas-Nall and Francis (1998) describe a solution-focused approach to risk assessment that
highlights the importance of supporting families to communicate about issues of
safety, concern and risk. They discuss the use of circular questioning (Selvini
et al., 1980) to gather perspectives from the young person and their family,
including their view of possible triggers, ideas about intervention or changes
in their context that might be helpful in reducing the risk of future harm.
A systemic approach to risk assessment highlights the importance of viewing risk
alongside the young person’s interaction with their environment and the systems
contained within it (Sutyemoto, 1998). It also moves away from locating the
problem within the child and instead locates it in the family system, and/or
impacted by the environment surrounding the individual.
2.5 A developmental approach
Throughout the assessment, it is
important to remember that CYP are not ‘small adults’, and that significant
modifications need to be made when assessing risk due to the individual’s
developmental stage, understanding of language and reliance on caregiver involvement.
It is important that the clinician considers the developmental stage of the
individual, as this may affect their perception, understanding and behaviours
in relation to risk. For example, when assessing SH in CYP, it is helpful to
clarify their understanding of what they understand the impact of SH and the
finality of death. Research supports an association between SH and impulsivity
(Hawton et al., 2012). Since the frontal cortex, that is responsible for
executive functions such as decision making and problem-solving does not
develop fully until early adulthood, the neurodevelopmental stage of the young
person should be considered (Anderson, 2010).<.p>
The CYP’s use and understanding of language
will impact how the risk assessment is carried out. For example, younger
children may deny suicidal thoughts when directly asked, however, this may be
because they do not use and understand that language. Pfeffer (1986) highlights
the importance of assessing suicidal ideation in younger children through
non-verbal’s, such as play. Whereas, CYP who are developmentally able to use
language to describe these concepts, risk assessment can be carried out more
verbally, with age-appropriate use of language[VR(CPT20] . Regardless of the age group, it is
important to consider the language that the young person is using, and for the
young person and the clinician to create a shared understanding of the difficulty[s21] .
2.5 Challenges of risk assessment
Assessing risk in CYP is a challenging task. The complex
interplay between risk and protective factors means that determining the level
of risk in a young person is challenging (Fox & Hawton, 2004). This issue is compounded by the fluidity of risk.
Since risk is shaped by contextual factors, the level of risk may change in a
short space of time. It highlights that risk assessment in CYP should not be a
one-off process, nor confined to risk assessment tools (Granello, 2010).
Confidentiality versus the safety of the person becomes more complex when working with CYP.
Throughout, practitioners need to consider how
to balance children’s rights and wishes with their responsibility to keep them
safe from harm[s22] . For
example, breaking confidentiality may cause harm to the young person by
damaging the therapeutic relationship, or pose harm by exacerbating unhealthy
family interactions in instances where the family are alerted to risk that they
were unaware. Furthermore, it is acknowledged that services cannot eliminate
risk, and there has been a move towards adopting a harm minimisation approach.
However, this can be a challenge by the very nature of the young person’s age
deeming them to require additional protection. Indeed, weighing the
balance of privacy, confidentiality and imminent risk is complex, and demands
consideration of what is ethically required.
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