Adopting a developmental lens: Assessing suicidal risk in children and adolescents

The death by suicide of a child or adolescent is considered rare when compared against other age groups, yet it is the leading cause of death in 5 to 17 year olds (ABS 2013) with rates of attempted suicide and self injury among the highest of all age groups (AIHW 2014). Despite the profound impact of the suicide of a child or adolescent, there are a number of concerns that have failed to come to the forefront of suicide prevention strategies for this population. Further, it has been long suggested that the rates of suicidality of children have been underestimated (Jackson, McCartt Hess & van Dalen 1995).

One of the possible explanations of this underestimate is the absence of a standardised and valid suicide risk assessment tool that is tailored to the emotional, intellectual and functional capacity of children which impairs psychologists and mental health practitioners from consistently assessing risk or measuring prevalence in this population. It has been suggested that clinicians are reluctant to complete comprehensive assessments of suicidality in children and young people due to reticence to accept that children comprehend death or that they could act to suicide (Jackson et al 1995; Barrio 2007). Although there are some screening tools and psychometric measures for adolescents, there are no such tools that are validated, reliable and developmentally appropriate for children under the age of 12, or sensitive to adolescents with specific developmental or intellectual needs.

Important factors to consider in assessing suicide risk in children and adolescents

Despite the lack of an established protocol or measure, there are a number of factors that clinicians should consider with respect to the assessment of suicidality for children and adolescents.

• Ensuring a careful, non-intrusive, developmentally sensitive approach

It is essential that clinicians maintain a careful and non-intrusive approach, appropriate to the child’s or adolescent’s developmental stage and capacity when completing suicide risk assessments. Taking an individualistic approach is critical with respect to understanding where the risks lie for a child; their concept of death, comprehension of permanency of death, belief system, formation of self-concept, core concerns, in addition to the broader situational, environmental and familial stressors or supports (Mishara 1999). Children and adolescents who are not confident in verbal expression should be supported to communicate through other means, such as drawing. Similarly, a child’s or adolescent’s developmental capacity must be considered in not only how they are interviewed, but how they are engaged in safety planning, for example, practicing de-escalation strategies that can be implemented independently with prompts for action that are readily recognised by the child.

• Being at the ready to mobilise interventions

Clinicians need to be immediately prepared to mobilise interventions and services in the event that a child demonstrates or reports increased risk for suicide or self injury (Barrio 2007). Such preparations include removal of means, preparedness to communicate risk and equip caregivers with risk management strategies as appropriate, safety planning and intervention planning.

• Working collaboratively and inclusively

It is strongly recommended that clinicians conducting suicide risk assessments and interventions work collaboratively with the family, however this can become complicated when considering children and young people at risk. Barrio (2007) highlights concerns in conducting an assessment where the care-giver is present as it may influence the child’s or adolescent’s response style or honesty regarding risk severity (Barrio 2007). Furthermore, where the child or adolescent is facing new or emerging concepts or difficulties related to personal and cultural identity, sexuality, mental health or social or online problems, assessments that expose the child or young person’s vulnerabilities prematurely to the family or others, could equally prove confronting if done without consideration for the impact on the family system.

Interventions may also extend to identifying social, school based, or broader community strategies. It is important to be aware that some of the recommended interventions may be met with resistance from the child or young person, for example if restrictions are imposed on social media use due to social media being identified as playing a role in the onset or planning for suicide. These types of interventions can be invaluable in equipping the child, family and community with skills that support resilience, positive coping attitudes and behaviours such as help seeking (Petrova, Wyman, Schmeelk-Cone & Pisani 2016). Such interventions could also be adapted to be culturally safe for higher risk groups, such as Aboriginal and Torres Strait Islander communities, where children and adolescents are at ten times the risk for suicide than non-Indigenous children and adolescents (Kolves & De Leo 2014).

The assessment of children and adolescents for risk of suicide and self-injury can therefore serve a two-fold function; firstly to prevent early death and disability, whilst promoting life and resilience, and secondly to intervene as early as possible in a potentially disturbing trajectory towards adult suicidality.

Suicide Risk Assessment Australia are running a range of workshops across Australia, including Children, Adolescents and Suicidal Behaviour – see our website for details

References

Australia Bureau of Statistics (2013) Suicide by age, cited December 2015, http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2013~Main%20Features~Suicide%20by%20Age~10010

AIHW: Harrison, J.E. & Henley, G. (2014) Suicide and hospitalised self-harm in Australia: trends and analysis. Injury research and statistics series no.93.Cat.no. INJCAT 169. Canberra: AIHW

Barrio, C. (2007) Assessing suicide risk in children: Guidelines for developmentally appropriate interviewing, Journal of Mental Health Counselling, Vol.29(1), pp.50-66.

Freuche, A., Kjelsberg, E. & Groholt, B. (2012) Suicide or accident? A psychological autopsy study of suicide in youths under the age of 16 compared to deaths labelled as accidents, Child and Adolescent Psychiatry and Mental Health, http://www.capmh.com/content/6/1/30

Jackson, H., McCartt Hess, P, & van Dalen, A. (1995) Preadolescent suicide: How to ask and how to respond, Families in Society, Vol.76(5), pp. 267-280

Kolves, K & De Leo, D. (2014) Suicide rates in children aged 10-14 years worldwide : changes in the past two decades. The British Journal of Psychiatry, Vol.205, pp.283-285.

Mishara, B. (1999) Concepts of death and suicide in children ages 6-12 and their implications for suicide prevention, Suicide and Life threatening Behaviour, Vol.29(2), pp.105-118

Petrova, M., Wyman, P., Schmeelk-Cone, K. & Pisani, A. (2016) Positive-themed suicide prevention messages delivered by adolescent peer leaders: Proximal impact on classmates’ coping attitudes and perceptions of adult support. Suicide and Life-threating Behaviour, Vol.45(6), pp.651-663.

By Carmen Betterridge & Fleur Taylor