Recently, KidsMatter had the honour of interviewing psychologist and Director of Suicide Risk Assessment Australia’s Carmen Betterridge on suicide prevention in children. Carmen is a registered psychologist with almost 15 years of experience working with clients experiencing social and economic disadvantage, from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander peoples and people affected by trauma and occupational distress. Carmen’s postgraduate qualifications are in indigenous health, forensic mental health and suicidology. Through the supervision of other psychologists undertaking psychological assessments, Carmen recognised the need for and importance of improved practitioner competence in suicide risk assessment and formulation. Carmen founded Suicide Risk Assessment Australia as a provider of best practice suicide risk assessment practices, imparting her knowledge and experience for other’s benefit.

Why is it important to talk about suicide prevention in children?

Being aware of the risk of suicide in children, no matter how rare, provides the opportunity to reduce the rate of suicide across all ages. Strategies can be established that mitigate risk, support a child to ask for and receive help, and manage risk factors like intense or confusing emotions – these are skills they can carry as they develop. Whist the risk may not be evident behaviourally in the younger years, we know that it rises sharply in adolescence. If we can understand the factors that increase risk in children, but also build resilience and support help-seeking behaviour, we may reduce the rates of suicide in adolescents and adults.

What does a prevention model for suicide look like?

There are a range of models and approaches to suicide prevention for adolescents and adults. However, in children, we don’t yet know the mechanisms for suicide risk onset or what factors need to be prioritised in preventative activities.

A primary prevention model teaches all children resilience, problem-solving and help-seeking behaviours and that stress and distress are normal experiences. A major component of teaching children resilience is supporting them to respond to distress in appropriate ways.

Working collaboratively with significant adults (eg. parents, family and teachers) in a child’s life is extremely important.  Children will probably learn about suicide indirectly, and it is important that open channels of communication with key adults are maintained so children can learn in a safe and supportive way.

Aiming for early intervention with children who may be at increased risk is critical. Identification of children who are disengaged or at risk of disengaging from school is important as this poses a risk factor for a range of difficulties in the later years.  Health and community professionals should focus on personalised support through the child’s school, family or care system and use social, psychological and behavioural strategies.

Parents (and care givers) are critical to the intervention process, and need to be supported with resources and strategies for responding to their child’s behaviour. As children look to their parents for cues to behavioural responses, parents need to feel supported so they can model appropriate and helpful behaviours for their child to internalise. Parents demonstrating help-seeking behaviour when they are struggling is also valuable for children to see.

There are some people who argue that suicide is not possible by children because they do not conceptually understand the permanence of death. What are your thoughts about this?

This is true in some cases. However, children progressively acquire an understanding of death, even if they don’t have the language to explain it.  Cognitive development (and capacity) plays a role in how a child understands death, but so does exposure to the principles of death (and suicide), whether through the death of loved ones and pets or discussions around terminal illnesses or near fatal injuries.  Children who have been exposed to the principles around death develop a more mature understanding of death earlier than children who haven’t had the same exposures.

What does the research say on children and suicide? Are there plans for further research on the topic?

Research into suicide in children is emerging, with great work by Australian Institute of Suicide Research and Prevention (AISRAP) among many others. This really is a vast area with more questions asked than can be currently answered. Australian research in the area is steadily growing, but a few factors that require further consideration relate to the role of social media in suicidal behaviours as well as specifically understanding those mechanisms that mitigate risk developing in children.

How would you suggest health and community practitioners go about assessing suicide risk in children? Are there any useful risk assessment tools for this age group?

There are currently no guidelines or recommendations in the assessment of suicide in children, with many tools typically validated on children over 12 years. There are no specific suicide assessment tools recommended for children under 12 years. Some suicide-specific risk assessment tools are in development, but fundamental to the use of a tool is an understanding of the context of the risk and the child’s account of what is occurring for them.

Some risk indicators to pay closer attention to include expressions of hopelessness and stories where a child describes wanting death or hating their life. A child may also relate more to or identify with someone or something that has died, where they fantasise about reuniting with their loved one and this requires careful understanding. The experience of conflict and rejection (from peers or family) is known to pose higher risk points for some adolescents and may also be relevant for children.

Children also might offer non-verbal signs that they aren’t coping, including taking risks or drawing disturbing images. However, we need to be cautious not to jump to conclusions, as over-reacting or responding in a way that is frightening to a child may inhibit them from disclosing or expressing themselves again.

What is the best way for health and community practitioners to support families whose child shows suicidal behaviour?

Working to support the child through the school, family and community as well as individually is very important, as suicidality reflects pain within the child’s relational system – family, community, school and internally. Families need to know how to understand their child’s behaviour and what is contributing to feelings of despair, hopelessness or even anger. Suicide is a complex behaviour – it is not a psychological disorder and suicidality needs to be conceptualised as a symptom of dysfunction within the child’s world, not purely their mind.

Health and community practitioners should seek to provide information to parents and key people (eg. teachers, siblings) in the child’s life on how to recognise and support a child to manage risky behaviour or emotions. Sometimes siblings are aware of the risk or despair but don’t recognise or understand what to do with that knowledge, which can also leave the sibling feeling powerless or guilty. Working to improve situational, contextual or environmental factors may also be necessary.

What role might health and community professionals play in supporting schools with this work?

Working towards open and direct communication between the family, practitioners and the school is the ideal goal, but it can also be very complicated. I have been aware of concerns held by schools about the risks for other students where suicidality or self-injury has been identified. Rather than continuing a sense of fear however, if we manage such risk respectfully, we hope that exclusion and fear doesn’t perpetuate stigma around these matters. Practitioners should seek to support, facilitate and encourage the school community to sensitively communicate about events in the child’s life, and support vulnerable children to implement intervention efforts. 

For more information:

Resources to support children's mental health