A quarter of children referred to mental health services in Scotland have been thinking about or attempted suicide—and face a postcode lottery as to whether they will be assessed or treated, a new study suggests.
Suicide among children and young people is a leading cause of death globally and, in the U.K., the number of suicides among under-25s has been continually rising since 2017. Scotland has the highest rate of suicides among children in the U.K.—however, the number referred to mental health services for suicidality, and the care they receive, is largely unknown.
Researchers at the University of Stirling have addressed this dearth of evidence by reviewing referrals to Child and Adolescent Mental Health Services (CAMHS) in two of Scotland’s NHS board areas. They found 25% of all referrals—those made to both boards across a six-month period—were for children who had been thinking about or had attempted suicide—and a third of those were under the age of 12.
The study also highlighted a significant disparity in the response of health boards to children referred for suicidality. In the first health board, more than two thirds (69%) were not offered a face-to-face assessment and just 8% of those assessed were offered treatment immediately. By contrast, the second health board—which had a specific suicide and self-harm team—offered face-to-face assessments to most (82%), with 66% of those offered treatment.
Dr. Lynne Gilmour led the study alongside colleagues from the Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP-RU) at the University of Stirling. She said, “In the U.K., children who have attempted suicide or have suicidal ideation are referred to Child and Adolescent Mental Health Services for assessment and treatment—however, little is known about the numbers referred for suicidality or the care they receive. This is of particular concern given CAMHS are under phenomenal pressure; staff are doing their utmost to provide timely and appropriate support, however, as our study shows, systems in place are not sufficient for the overall numbers being referred; some services are overwhelmed—and this has been further exacerbated by the pandemic.
“Our research sought to understand how the children referred for suicidality are processed, assessed and treated. Overall, we found that one in four referrals to CAMHS involved children who had either attempted suicide or had suicidal ideation—and 33% of those were under 12.
“We also identified a variation within and between health boards in terms of assessment, referral outcomes, and care pathways for these children—with most, in one area, not receiving a face-to-face assessment, let alone treatment or support. This highlights the often-missed yet vital opportunity for early intervention with very young suicidal children.”
Using anonymized data, the research team examined referrals made—often by medical professionals, schools, or social workers—to two CAMHS sites situated in different parts of Scotland (sites A and B) between January and June 2019.
At site A, 104 of all 397 referrals (26%) to CAMHS were identified as being for suicidality, and 180 of 762 (24%) at site B. Around 40% of those referrals were for males and 60% for females, and ages spanned from five to 17. Researchers said that there was a “considerable difference” between the sites in terms of the numbers who were offered assessments and treatment, reflecting the structural differences between the teams. At site A, just 31% of children were offered a face-to-face assessment—which generally involves meeting a clinician who will conduct a risk assessment, safety planning exploration of family circumstances, and underlying issues. This compared to 82% at site B.
At site A, just 8% were offered treatment immediately, with 34.6% added to a waiting list and 57.6% of referrals rejected. In contrast, at site B—which had its own suicide and self-harm team—66.1% were offered treatment, 20.5% were either added to waiting list or referred to another CAMHS service, and 13.3% were signposted or redirected.
“Having a dedicated team to respond to referrals for suicidality appears to support access to assessment and treatment,” the authors said.
Underlying issues identified by referrers were similar across both sites, including: domestic abuse, child abuse (physical, emotional, sexual, neglect), bullying, autism spectrum disorders, and other mental health issues.
Dr. Gilmour, who has presented the findings to the Scottish Government, added, “Our study highlights vast differences in how referrals for suicidality in children are processed and responded to. We found little difference in the issues being identified by referrers, the age range of children, and the behaviors they present; yet there were very different outcomes and pathways of care.
“The data presented here is novel and will provide a vital source of information for decision-makers and service providers in their consideration of service structures and allocation of resources. This is particularly important giving the growing number of referrals to CAMHS and the excessively long waiting times in many areas: it is vital that those identified as being at risk of suicide be provided with clear and consistent pathways of care at the earliest possible opportunity.”
The research is part of a wider study that is also exploring the experiences of children, parents and CAHMS staff. Dr. Gilmour—co-Principal Investigator on the National Suicide Prevention Leadership Group’s Youth Advisory Group—is supported in the study by fellow NMAHP-RU colleagues Professor Margaret Maxwell, Professor Edward Duncan, and Dr. Catherine Best. The paper, “Characteristics and outcomes of referrals to CAMHS for children who are thinking about or attempted suicide: A retrospective cohort study in two Scottish CAMHS,” is published in the Frontiers in Psychiatry journal.