Table 1: Assessment tool to determine the level of risk of suicide for a young person
During the interview with the young person, investigate each of the areas in the column on the left and CIRCLE THE RELEVANT DESCRIPTION OF THE YOUNG PERSON’S CURRENT SITUATION. In investigating any suicide plan (note 4 below), it is important to use direct questions as the young person is likely to be reluctant to volunteer the information. Direct questioning will not aggravate the risk of suicide but failure to fully investigate, categorise the risk and respond appropriately may result in a suicide that could have been avoided. On the basis of the young person’s responses, determine which of the three risk levels: LOW, MODERATE or HIGH, best describes the situation. If there is any risk then proceed with the management plan (Table 2).
Moderate: some moodiness, sadness, irritability, loneliness and decrease of energy
Many recent social/personal crises
Overwhelmed with hopelessness, sadness and anger (verbal/physical), feelings of worthlessness
Extreme mood changes
Delusions, paranoia, lost touch with reality
Ongoing life difficulties
Significant trauma
Sexual identity issues
Family difficulties
Minimal impact but aware of some potential difficulties
Having some impact on everyday life
Major concerns, impacting on many areas of their life
Cultural issues
Minimal impact
Having some impact on everyday life
Major concerns, impacting on many areas of their life
Coping behaviour
Only occasional thoughts about suicide
Daily activities continue as usual with little change
Recurring thoughts of suicide
Intentional self-harming without expressed suicidal intent eg: cutting
Some daily activities disrupted; disturbance in eating, sleeping, school work
May resist help
Constant suicidal thoughts
Significant disturbances in daily functioning
Participation in high risk behaviours (ie: alcohol and drug abuse, potential for accidents etc)
2. Positive resources
Family and friends
Help available; significant others concerned and willing to help
Family and friends available but unwilling to help consistently
Family and friends not available or hostile, exhausted, injurious
Significant self neglect
Lifestyle
Stable family relationships, personality and school performance
Recent acting out behaviour and substance abuse
Acute suicidal behaviour in stable personality
Suicidal behaviour in unstable personality; emotional disturbance; repeated difficulty with peers, family
Communication
Direct expression of feelings and suicidal thoughts associated with distress and active help seeking
Interpersonalised suicide goal (“They’ll be sorry”, “I’ll show them”, “I don’t deserve to live” or “I want to be with someone who has died”)
Very indirect or non-verbal expression of internalised suicide goal (guilt, worthlessness)
3. Previous suicide attempts
None or one of low lethality (see 4.4 for lethality)
Multiple of low lethality or one of medium lethality; history of repeated threats (see 4.4 for lethality)
Suicide among family or friends
One of high lethality or multiple of moderate lethality
Several attempts over the last weeks and/or suicide among family or friends
4. Suicide plan
Details
Availability of means
Time
Lethality of method
Chance of intervention
Vague
Not available
No specific time or in the future
Pills or slash wrists
Others present most of the time
Some specifics
Available, has close by
Within a few hours
Drugs and alcohol, and car accident
Others available if called on
Well thought out; knows when, where, how
Has means at hand
Immediately
Gun, hanging, jumping, carbon monoxide
No one nearby; isolated
Table 2: Managing suicide risk in young people
Select column relevant to level of risk identified in assessment. Suicide risk fluctuates and management needs to be adjusted accordingly.
Action
Low Risk
Moderate Risk
High Risk
Reduce risk
Remove means to harm themselves
Establish an appropriate regime to monitor young person
Check on family’s/friends’ support as appropriate, provide information on resources centred around the needs of the young person
In collaboration with young person and support people, write a clear action plan
Remove means to harm themselves
Ensure young person has appropriate support eg: family/whānau, friends
Arrange back-up support which is available 24 hours a day
In collaboration with young person and support people, write a clear action plan
Remove means to harm themselves (in extreme circumstances this may mean calling the police)
Involves all management outlined in moderate risk, but urgent action is required
Support and supervise at all times until responsibility is passed to another agency or individual
Make urgent referral to mental health team
Consultation and Referral
Consider discussing case with a colleague or specialist mental health provider
Children, Young Persons and their Families Agency (CYPFA) must be informed where care and protection are required (under 17 years)*
Check if any other services are involved and who has responsibility for coordination eg: school counsellor, Specialist Education Services, CYPFA or mental health services
Network with school or educational institution
Consult with or refer to specialist cultural health service prior to other agency consultation for Māori
Consult with or refer to mental health services on the same day
Involve family/whānau, friends if permission given or arrange alternative support**
CYPFA must be informed where care and protection are required (for 17 years and under)
Recommend to young person and support people appropriate agencies or other resources, and assist them in accessing these services
Ensure there is a management plan in collaboration with all services involved
If immediate referral is not possible, mobilise professional networks to assist in the management, support and supervision of the young person in consultation with mental health professional
Contact family/whānau, friends if not already present and involve as appropriate
CYPFA must be informed where care and protection are required (for 17 years and under)
Consider arranging assessment under the Mental Health Act if appropriate
Ensure there is a management plan in collaboration with all services involved with explicit handover of responsibility between agencies or professionals
Manage underlying factors
Initiate/optimise treatment of any underlying mental disorders or problems
Assist the young person and family to address any immediate precipitating factors and ongoing life difficulties
Must initiate/optimise treatment for any underlying mental disorders or problems
Assist the young person and family to address any immediate precipitating factors and ongoing life difficulties
Must initiate/optimise treatment for any underlying mental disorders or problems
Assist the young person and family to address any immediate precipitating factors and ongoing life difficulties (undertaken in most cases by the specialist mental health services)
Monitor and follow up
Make regular follow-up appointments
Monitor changes in suicide risk
Telephone contact may suffice
If no improvement in one to two weeks treat as moderate risk
Make regular follow-up appointments
Contact regularly
Monitor changes in suicide risk
Check outcome of any agency referrals
Ensure the following processes are in place and working effectively
Make regular follow-up appointments
Contact regularly
Monitor changes in suicide risk
Check outcome of any agency referrals
(Adapted from Ministry of Education, 1997 Young People at Risk of Suicide: A Guide for Schools)
* This may include family’s inability or unwillingness to provide care, support and monitoring.
** If there is serious or imminent threat to the young person’s life, permission to contact family/support people is not required, decisions must be made in the interests of safety.
